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©2013 UpToDate ® Print Email ACC/AHA/HRS guideline summary: Indications for permanent pacing in acquired atrioventricular (AV) block in adults Class I - There is evidence and/or general agreement that permanent pacing is indicated in adults with (acquired AV block) in the following settings: • Third-degree and advanced second-degree AV block at any anatomic level: 1. Associated with bradycardia with symptoms (including heart failure) or ventricular arrhythmias presumed to be due to AV block. (Level of Evidence: C) 2. Associated with arrhythmias and other medical conditions that require drug therapy that results in symptomatic bradycardia. (Level of Evidence: C) 3. In awake, symptom-free patients in sinus rhythm, with documented periods of asystole ≥3.0 seconds or any escape rate <40 bpm, or with an escape rhythm that is below the AV node. (Level of Evidence: C) 4. In awake, symptom-free patients with AF and bradycardia with 1 or more pauses of at least 5 seconds or longer. (Level of Evidence: C) 5. After catheter ablation of the AV junction. (Level of Evidence: C) 6. Associated with postoperative AV block that is not expected to resolve after cardiac surgery. (Level of Evidence: C) 7. Associated with neuromuscular diseases with AV block, such as myotonic muscular dystrophy, Kearns-Sayre syndrome, Erb dystrophy (limb-girdle muscular dystrophy), and peroneal muscular atrophy, with or without symptoms. (Level of Evidence: B) • Second-degree AV block with associated symptomatic bradycardia regardless of type or site of block. (Level of Evidence: B) • Asymptomatic persistent third-degree AV block at any anatomic site with average awake ventricular rates of 40 bpm or faster if cardiomegaly or LV dysfunction is present or if the site of block is below the AV node. (Level of Evidence: B) • Second- or third-degree AV block during exercise in the absence of myocardial ischemia. (Level of Evidence: C) Class IIa - The weight of evidence or opinion is in favor of the usefulness of permanent pacing in adults with (acquired AV block) in the following settings: • Persistent third-degree AV block with an escape rate >40 bpm in asymptomatic adult patients without cardiomegaly. (Level of Evidence: C) • Asymptomatic second-degree AV block at intra- or infra-His levels found at electrophysiological study. (Level of Evidence: B)

Class IIa - The weight of evidence or opinion is in favor of the usefulness of permanent pacing in adults with (acquired AV block) in the following settings: • Persistent third-degree AV block with an escape rate >40 bpm in asymptomatic adult patients without cardiomegaly. (Level of Evidence: C) • Asymptomatic second-degree AV block at intra- or infra-His levels found at electrophysiological study. (Level of Evidence: B) • First- or second-degree AV block with symptoms similar to those of pacemaker syndrome or hemodynamic compromise. (Level of Evidence: B) • Asymptomatic type II second-degree AV block with a narrow QRS. When type II second-degree AV block occurs with a wide QRS, including isolated right bundle-branch block, pacing becomes a Class I recommendation. (Level of Evidence: B) Class IIb - The weight of evidence or opinion is less well established for the usefulness of permanent pacing in adults with acquired AV block in the following settings: • Neuromuscular diseases such as myotonic muscular dystrophy, Erb dystrophy (limb-girdle muscular dystrophy), and peroneal muscular atrophy with any degree of AV block (including first-degree AV block), with or without symptoms, because there may be unpredictable progression of AV conduction disease. (Level of Evidence: B) • AV block in the setting of drug use and/or drug toxicity when the block is expected to recur even after the drug is withdrawn. (Level of Evidence: B) Class III - There is evidence and/or general agreement that permanent pacing in adults with acquired AV block is not useful in in the following settings: • Asymptomatic first-degree AV block. (Level of Evidence: B) • Asymptomatic type I second-degree AV block at the supra-His (AV node) level or that which is not known to be intra- or infra-Hisian. (Level of Evidence: C) • AV block that is expected to resolve and is unlikely to recur (e.g., drug toxicity, Lyme disease, or transient increases in vagal tone or during hypoxia in sleep apnea syndrome in the absence of symptoms). (Level of Evidence: B)

• Asymptomatic type I second-degree AV block at the supra-His (AV node) level or that which is not known to be intra- or infra-Hisian. (Level of Evidence: C) • AV block that is expected to resolve and is unlikely to recur (e.g., drug toxicity, Lyme disease, or transient increases in vagal tone or during hypoxia in sleep apnea syndrome in the absence of symptoms). (Level of Evidence: B) Adapted from Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation 2008; 117:e350.