2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy : The Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA)
TL;DR: 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy : The Task Force on cardiac paced and resynchronized therapy of the European Society of Cardiology developed in collaboration with the European Heart Rhythm Association.
Abstract: ### Abbreviations
1st AV
: First-degree atrioventricular block
AF
: atrial fibrillation
AT
: atrial tachyarrhythmia
ATP
: Anti-tachycardia pacing
AV
: atrioventricular
BBB
: bundle branch block
CHF
: congestive heart failure
CI
: confidence interval
CPG
: Committee for Practice Guidelines
CRT
: cardiac resynchronization therapy
CRT-D
: cardiac resynchronization therapy and defibrillator
CRT-P
: cardiac resynchronization therapy and pacemaker
ECG
: electrocardiogram
EDMD
: Emery-Dreifuss muscular dystrophy
EF
: ejection fraction
EPS
: electrophysiological study
ESC
: European Society of Cardiology
HCM
: hypertrophic cardiomyopathy
HF
: heart failure
HR
: hazard ratio
HV
: His-ventricular
ICD
: implantable cardioverter defibrillator
ILR
: implantable loop recorder
IVCD
: intraventricular conduction delay
LBBB
: left bundle branch block
LQTS
: long QT syndrome
LV
: left ventricular
LVEF
: left ventricular ejection fraction
LVSD
: left ventricular systolic dysfunction
MR
: mitral regurgitation
MRI
: magnetic resonance imaging
NYHA
: New York Heart Association
PM
: pacemaker
OR
: odds ratio
QALY
: quality-adjusted life year
RBBB
: right bundle branch block
RCT
: randomized controlled trial
RV
: right ventricular
SB
: sinus bradycardia
SNRT
: sinus node recovery time
SR
: sinus rhythm
SSS
: sick sinus syndrome
TAVI
: transcatheter aortic valve implantation
VF
: ventricular fibrillation
VT
: ventricular tachycardia
VV
: interventricular (delay)
### Acronyms of the trials referenced in the recommendations or reported in the tables
ADEPT
: ADvanced Elements of Pacing Randomized Controlled Trial
ADOPT
: Atrial Dynamic Overdrive Pacing Trial
AOPS
: Atrial Overdrive Pacing Study
APAF
: Ablate and Pace in Atrial Fibrillation
ASSERT
: ASymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial
ATTEST
: ATrial Therapy Efficacy and Safety Trial
AVAIL CLS/CRT
: AV Node Ablation with CLS and CRT Pacing Therapies for Treatment of AF trial
B4
: Bradycardia detection in Bundle Branch Block
BELIEVE
: Bi vs. Left Ventricular Pacing: an International Pilot Evaluation on Heart Failure Patients with Ventricular Arrhythmias
BIOPACE
: Biventricular pacing for atrioventricular block to prevent cardiac desynchronization
BLOCK-HF
: Biventricular versus right ventricular pacing in patients with AV block
B-LEFT
: Biventricular versus LEFT Univentricular Pacing with ICD Back-up in Heart Failure Patients
CARE-HF
: CArdiac REsynchronization in Heart Failure
CLEAR
: CLinical Evaluation on Advanced Resynchronization
COMBAT
: COnventional vs. Biventricular Pacing in Heart Failure and Bradyarrhythmia
COMPANION
: COmparison of Medical Therapy, Pacing and Defibrillation in Heart Failure
DANPACE
: DANish Multicenter Randomized Trial on Single Lead Atrial PACing vs. Dual Chamber Pacing in Sick Sinus Syndrome
DECREASE-HF
: The Device Evaluation of CONTAK RENEWAL 2 and EASYTRAK 2: Assessment of Safety and Effectiveness in Heart Failure
FREEDOM
: Optimization Study Using the QuickOpt Method
GREATER-EARTH
: Evaluation of Resynchronization Therapy for Heart Failure in Patients with a QRS Duration GREATER Than 120 ms
LESSER-EARTH
: Evaluation of Resynchronization Therapy for Heart Failure in Patients with a QRS Duration Lower Than 120 ms
HOBIPACE
: HOmburg BIventricular PACing Evaluation
IN-CHF
: Italian Network on Congestive Heart Failure
ISSUE
: International Study on Syncope of Unexplained Etiology
MADIT
: Multicenter Automatic Defibrillator Trial
MIRACLE
: Multicenter InSync RAndomized CLinical Evaluation
MOST
: MOde Selection Trial in Sinus-Node Dysfunction
MUSTIC
: MUltisite STimulation In Cardiomyopathies
OPSITE
: Optimal Pacing SITE
PACE
: Pacing to Avoid Cardiac Enlargement
PAVE
: Left Ventricular-Based Cardiac Stimulation Post AV Nodal Ablation Evaluation
PATH-CHF
: PAcing THerapies in Congestive Heart Failure II Study Group
PIPAF
: Pacing In Prevention of Atrial Fibrillation Study
PIRAT
: Prevention of Immediate Reinitiation of Atrial Tachyarrhythmias
POT
: Prevention Or Termination Study
PREVENT-HF
: PREventing VENTricular Dysfunction in Pacemaker Patients Without Advanced Heart Failure
PROSPECT
: PRedictors Of Response to Cardiac Resynchronization Therapy
RAFT
: Resynchronization–Defibrillation for Ambulatory Heart Failure Trial
RethinQ
: Cardiac REsynchronization THerapy IN Patients with Heart Failure and Narrow QRS
REVERSE
: REsynchronization reVErses Remodelling in Systolic left vEntricular dysfunction
SAFARI
: Study of Atrial Fibrillation Reduction
SCD HeFT
: Sudden Cardiac Death in Heart Failure Trial
SMART-AV
: The SMARTDelay Determined AV Optimization: a Comparison with Other AV Delay Methods Used in Cardiac Resynchronization Therapy
SYDIT
: The SYncope DIagnosis and Treatment
SYNPACE
: Vasovagal SYNcope and PACing
TARGET
: TARgeted Left Ventricular Lead Placement to Guide Cardiac Resynchronization Therapy
THEOPACE
: Effects of Oral THEOphylline and of Permanent PACEmaker on the Symptoms and Complications of Sick Sinus Syndrome
VASIS-PM
: VAsovagal Syncope International Study on PaceMaker therapy
V-HeFT
: Vasodilator in HEart Failure Trial
VPSII
: Second Vasovagal Pacemaker Study (VPS II)
Additional references are mentioned with ‘w’ in the main text and can be found on the online addenda along with 5 figures (1, 6, 7, 9, 11, 12) and 10 tables (3, 4, 5, 9, 11, 12, 19, 21, 22, 23). They are available on the ESC website only at http://www.escardio.org/guidelines-surveys/esc-guidelines/Pages/cardiac-pacing-and-cardiac-resynchronisation-therapy.aspx
Guidelines summarize and evaluate all available evidence, at the time of the writing process, on a …
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TL;DR: Authors/Task Force Members: Piotr Ponikowski* (Chairperson) (Poland), Adriaan A. Voors* (Co-Chair person) (The Netherlands), Stefan D. Anker (Germany), Héctor Bueno (Spain), John G. F. Cleland (UK), Andrew J. S. Coats (UK)
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Abstract: ACE
: angiotensin-converting enzyme
ACS
: acute coronary syndrome
ADP
: adenosine diphosphate
AF
: atrial fibrillation
AMI
: acute myocardial infarction
AV
: atrioventricular
AIDA-4
: Abciximab Intracoronary vs. intravenously Drug Application
APACHE II
: Acute Physiology Aand Chronic
7,519 citations
TL;DR: ACCF/AHAIAI: angiotensin-converting enzyme inhibitor as discussed by the authors, angio-catabolizing enzyme inhibitor inhibitor inhibitor (ACS inhibitor) is a drug that is used to prevent atrial fibrillation.
Abstract: ACC/AHA
: American College of Cardiology/American Heart Association
ACCF/AHA
: American College of Cardiology Foundation/American Heart Association
ACE
: angiotensin-converting enzyme
ACEI
: angiotensin-converting enzyme inhibitor
ACS
: acute coronary syndrome
AF
: atrial fibrillation
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Abstract: 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC)
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Cites methods from "2013 ESC Guidelines on cardiac paci..."
...Indications for pacing are outlined in detail in the ESC Guidelines for cardiac pacing and cardiac resynchronization therapy.(469) Management of ventricular arrhythmias and conduc-...
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TL;DR: The Task Force for the management of atrial fibrillation of the European Society of Cardiology has been endorsed by the European Stroke Organisation (ESO).
Abstract: The Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC)
Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC
Endorsed by the European Stroke Organisation (ESO)
5,255 citations
Additional excerpts
...Atrial fibrillation patients with heart failure with mid-range ejection 746 fraction 747 HFmrEF is a recently defined entity, describing patients with symptoms and signs of heart failure, LVEF 40–748 49%, elevated levels of natriuretic peptides, and either LV hypertrophy, left atrial (LA) enlargement, or 749 evidence of diastolic dysfunction.222 However, diagnosis is more difficult in patients with AF, as natriuretic 750 peptides are elevated in AF and LA dilatation is common, regardless of concomitant heart failure....
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...%) and reduced ejection fraction (LVEF < 40%),219, 220 suffer from a 688 worse prognosis, including increased mortality.16, 221 The recent ESC Guidelines on heart failure222 have also 689 introduced a new category of heart failure with mid-range ejection fraction (HFmrEF; LVEF 40–49%), although 690 data on AF patients in this group are currently limited....
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...LVEF is also 751 variable and difficult to assess in AF patients because of AF-induced reduction in systolic LV function and 752 Page 25 of 148 ESC AF Guidelines variable cardiac cycle length....
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...Prevention of adverse outcomes and maintenance of a 691 good quality of life are the aims of management in all patients with AF and concomitant heart failure, regardless 692 Page 23 of 148 ESC AF Guidelines of LVEF.223 The general approach to AF management does not differ between heart failure patients and others, 693 but a few considerations are worthwhile to consider....
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...patient characteristics, including LVEF [573, 574]....
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References
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14 Apr 2005
TL;DR: Cardiac resynchronization has been shown to reduce symptoms and improve left ventricular function in patients with heart failure due to systolic dysfunction and cardiac dyssynchrony.
Abstract: background Cardiac resynchronization reduces symptoms and improves left ventricular function in many patients with heart failure due to left ventricular systolic dysfunction and cardiac dyssynchrony We evaluated its effects on morbidity and mortality methods Patients with New York Heart Association class III or IV heart failure due to left ventricular systolic dysfunction and cardiac dyssynchrony who were receiving standard pharmacologic therapy were randomly assigned to receive medical therapy alone or with cardiac resynchronization The primary end point was the time to death from any cause or an unplanned hospitalization for a major cardiovascular event The principal secondary end point was death from any cause results A total of 813 patients were enrolled and followed for a mean of 294 months The primary end point was reached by 159 patients in the cardiac-resynchronization group, as compared with 224 patients in the medical-therapy group (39 percent vs 55 percent; hazard ratio, 063; 95 percent confidence interval, 051 to 077; P<0001) There were 82 deaths in the cardiac-resynchronization group, as compared with 120 in the medical-therapy group (20 percent vs 30 percent; hazard ratio 064; 95 percent confidence interval, 048 to 085; P<0002) As compared with medical therapy, cardiac resynchronization reduced the interventricular mechanical delay, the end-systolic volume index, and the area of the mitral regurgitant jet; increased the left ventricular ejection fraction; and improved symptoms and the quality of life (P<001 for all comparisons) conclusions In patients with heart failure and cardiac dyssynchrony, cardiac resynchronization improves symptoms and the quality of life and reduces complications and the risk of death These benefits are in addition to those afforded by standard pharmacologic therapy The implantation of a cardiac-resynchronization device should routinely be considered in such patients
5,493 citations
Anschutz Medical Campus1, University of Southern California2, Pennsylvania State University3, Memorial Hospital of South Bend4, Johns Hopkins University5, University of California, San Francisco6, United States Department of Veterans Affairs7, Pfizer8, University of Wisconsin-Madison9, Boston Scientific Corporation10, Thomas Jefferson University11
TL;DR: In this paper, the authors tested the hypothesis that prophylactic cardiac-resynchronization therapy in the form of biventricular stimulation with a pacemaker with or without a defibrillator would reduce the risk of death and hospitalization among patients with advanced chronic heart failure and intraventricular conduction delays.
Abstract: background We tested the hypothesis that prophylactic cardiac-resynchronization therapy in the form of biventricular stimulation with a pacemaker with or without a defibrillator would reduce the risk of death and hospitalization among patients with advanced chronic heart failure and intraventricular conduction delays. methods A total of 1520 patients who had advanced heart failure (New York Heart Association class III or IV) due to ischemic or nonischemic cardiomyopathies and a QRS interval of at least 120 msec were randomly assigned in a 1:2:2 ratio to receive optimal pharmacologic therapy (diuretics, angiotensin-converting–enzyme inhibitors, beta-blockers, and spironolactone) alone or in combination with cardiac-resynchronization therapy with either a pacemaker or a pacemaker–defibrillator. The primary composite end point was the time to death from or hospitalization for any cause. results As compared with optimal pharmacologic therapy alone, cardiac-resynchronization therapy with a pacemaker decreased the risk of the primary end point (hazard ratio, 0.81; P=0.014), as did cardiac-resynchronization therapy with a pacemaker–defibrillator (hazard ratio, 0.80; P=0.01). The risk of the combined end point of death from or hospitalization for heart failure was reduced by 34 percent in the pacemaker group (P<0.002) and by 40 percent in the pacemaker–defibrillator group (P<0.001 for the comparison with the pharmacologic-therapy group). A pacemaker reduced the risk of the secondary end point of death from any cause by 24 percent (P=0.059), and a pacemaker–defibrillator reduced the risk by 36 percent (P=0.003). conclusions In patients with advanced heart failure and a prolonged QRS interval, cardiac-resynchronization therapy decreases the combined risk of death from any cause or first hospitalization and, when combined with an implantable defibrillator, significantly reduces mortality.
5,132 citations
TL;DR: Cardiac resynchronization results in significant clinical improvement in patients who have moderate-to-severe heart failure and an intraventricular conduction delay.
Abstract: Background Previous studies have suggested that cardiac resynchronization achieved through atrial-synchronized biventricular pacing produces clinical benefits in patients with heart failure who have an intraventricular conduction delay. We conducted a double-blind trial to evaluate this therapeutic approach. Methods Four hundred fifty-three patients with moderate-to-severe symptoms of heart failure associated with an ejection fraction of 35 percent or less and a QRS interval of 130 msec or more were randomly assigned to a cardiac-resynchronization group (228 patients) or to a control group (225 patients) for six months, while conventional therapy for heart failure was maintained. The primary end points were the New York Heart Association functional class, quality of life, and the distance walked in six minutes. Results As compared with the control group, patients assigned to cardiac resynchronization experienced an improvement in the distance walked in six minutes (+39 vs. +10 m, P=0.005), functional clas...
4,329 citations
TL;DR: CRT combined with ICD decreased the risk of heart-failure events in relatively asymptomatic patients with a low ejection fraction and wide QRS complex and was associated with a significant reduction in left ventricular volumes and improvement in the ejectedion fraction.
Abstract: During a 4.5-year period, we enrolled and followed 1820 patients with ischemic or nonischemic cardiomyopathy, an ejection fraction of 30% or less, a QRS duration of 130 msec or more, and New York Heart Association class I or II symptoms. Patients were randomly assigned in a 3:2 ratio to receive CRT plus an implantable cardioverter– defibrillator (ICD) (1089 patients) or an ICD alone (731 patients). The primary end point was death from any cause or a nonfatal heart-failure event (whichever came first). Heartfailure events were diagnosed by physicians who were aware of the treatment assignments, but they were adjudicated by a committee that was unaware of assignments. Results During an average follow-up of 2.4 years, the primary end point occurred in 187 of 1089 patients in the CRT–ICD group (17.2%) and 185 of 731 patients in the ICD-only group (25.3%) (hazard ratio in the CRT–ICD group, 0.66; 95% confidence interval [CI], 0.52 to 0.84; P = 0.001). The benefit did not differ significantly between patients with ischemic cardiomyopathy and those with nonischemic cardiomyopathy. The superiority of CRT was driven by a 41% reduction in the risk of heart-failure events, a finding that was evident primarily in a prespecified subgroup of patients with a QRS duration of 150 msec or more. CRT was associated with a significant reduction in left ventricular volumes and improvement in the ejection fraction. There was no significant difference between the two groups in the overall risk of death, with a 3% annual mortality rate in each treatment group. Serious adverse events were infrequent in the two groups. Conclusions CRT combined with ICD decreased the risk of heart-failure events in relatively asymptomatic patients with a low ejection fraction and wide QRS complex. (ClinicalTrials.gov number, NCT00180271.)
2,592 citations
"2013 ESC Guidelines on cardiac paci..." refers methods in this paper
...Imaging techniques may be able to identify those patients who will respond favourably to CRT.w114,w115 A sub-analysis of data collected in the CARE-HF trial showed that an interventricular mechanical delay (measured as the time difference between onset of pulmonary and aortic flow in pulsed wave Doppler spectral recordings) ≥49.2 ms was an independent predictor of response to CRT.w116 Many observational studies have demonstrated that the presence of LV dyssynchrony is associated with improved outcomes in patients treated with CRT....
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...It is important to emphasize that the use of AV junction ablation was highly variable between the different studies, ranging from 15%97 to 100%.90 The decision to perform AV junction ablation is still a matter of debate but most studies demonstrate a beneficial effect of enhancing the effects of CRT.98– 102 In these studies, patients with AF without AV junction ablation had a worse response to CRT than patients in SR or AF with AV junction ablation....
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...There were few clinical events with a trend in favour of CRT....
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...Pre-specified subgroup analyses of data collected in the MADIT-CRT, REVERSE and Resynchronization–Defibrillation for Ambulatory Heart Failure Trial (RAFT) trials demonstrated that patients with a QRS duration ≥150 ms benefited most from CRT.50,61,62 Meta-analyses using aggregate data from randomized trials showed that CRT was effective in reducing adverse clinical events in patients with baseline QRS duration ≥150 ms and suggested that CRT might not reduce events in patients with a QRS ,150 ms.58 Sub-group analyses based on QRS morphology in the MADIT-CRT, RAFT and REVERSE trials,48,50,62,63 and a meta-analysis of COMPANION, CARE-HF, MADIT-CRT and RAFT,64 suggested that patients with complete LBBB (defined in Web Table 11) showed a greater benefit on the composite of morbidity/mortality from CRT, compared with patients with non-specific IVCD or RBBB....
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...Post-hoc analyser fra disse studier har vist, at undergruppen af patienter med QRS 120-150 ms i gennemsnit ikke profiterer af CRT. Der er imidlertid ikke et studie der direkte tester effekten af CRT på patienter med QRS 120-150 ms. Det er nyligt dokumenteret i EchoCRT studiet, at CRT ikke er gavnligt ved kort QRS (gennemsnitligt QRS 105 ms i studiet)....
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TL;DR: In this article, transvenous atriobiventricular pacemakers (with leads in one atrium and each ventricle) were used to reduce ventricular asynchrony.
Abstract: BACKGROUND: One third of patients with chronic heart failure have electrocardiographic evidence of a major intraventricular conduction delay, which may worsen left ventricular systolic dysfunction through asynchronous ventricular contraction. Uncontrolled studies suggest that multisite biventricular pacing improves hemodynamics and well-being by reducing ventricular asynchrony. We assessed the clinical efficacy and safety of this new therapy. METHODS: Sixty-seven patients with severe heart failure (New York Heart Association class III) due to chronic left ventricular systolic dysfunction, with normal sinus rhythm and a duration of the QRS interval of more than 150 msec, received transvenous atriobiventricular pacemakers (with leads in one atrium and each ventricle). This single-blind, randomized, controlled crossover study compared the responses of the patients during two periods: a three-month period of inactive pacing (ventricular inhibited pacing at a basic rate of 40 bpm) and a three-month period of active (atriobiventricular) pacing. The primary end point was the distance walked in six minutes; the secondary end points were the quality of life as measured by questionnaire, peak oxygen consumption, hospitalizations related to heart failure, the patients' treatment preference (active vs. inactive pacing), and the mortality rate. RESULTS: Nine patients were withdrawn from the study before randomization, and 10 failed to complete both study periods. Thus, 48 patients completed both phases of the study. The mean distance walked in six minutes was 22 percent greater with active pacing (399+/-100 m vs. 326+/-134 m, P<0.001), the quality-of-life score improved by 32 percent (P<0.001), peak oxygen uptake increased by 8 percent (P<0.03), hospitalizations were decreased by two thirds (P<0.05), and active pacing was preferred by 85 percent of the patients (P<0.001). CONCLUSIONS: Although it is technically complex, atriobiventricular pacing significantly improves exercise tolerance and quality of life in patients with chronic heart failure and intraventricular conduction delay.
2,540 citations