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©2013 UpToDate ® Print Email ACC/AHA/HRS guideline summary: Indications for permanent pacing in chronic bifascicular block Class I - There is evidence and/or general agreement that permanent pacing is indicated in patients with chronic bifascicular block in the following settings: • Advanced second-degree AV block or intermittent third-degree AV block. (Level of Evidence: B) • Type II second-degree AV block. (Level of Evidence: B) • Alternating bundle branch block. (Level of Evidence: C) Class IIa - The weight of evidence or opinion is in favor of the usefulness of permanent pacing in patients with chronic bifascicular block in the following settings: • Syncope not demonstrated to be due to AV block when other likely causes have been excluded, specifically ventricular tachycardia (VT). (Level of Evidence: B) • Incidental finding at electrophysiological study of a markedly prolonged HV interval (≥100 msec) in asymptomatic patients. (Level of Evidence: B) • Incidental finding at electrophysiological study of pacing-induced infra-His block that is not physiological. (Level of Evidence: B) Class IIb - The weight of evidence or opinion is less well established for the usefulness of permanent pacing in patients with chronic bifascicular block in the following setting: • Neuromuscular diseases, such as myotonic muscular dystrophy, Erb dystrophy (limb-girdle muscular dystrophy), and peroneal muscular atrophy with bifascicular block or any fascicular block, with or without symptoms. (Level of Evidence: C) Class III - There is evidence and/or general agreement that permanent pacing for chronic bifascicular block is not useful in in the following settings: • Fascicular block without AV block or symptoms. (Level of Evidence: B) • Fascicular block with first-degree AV block without 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. Indications for pacing in multifascicular block Pacemaker necessary Pacemaker probably necessary

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. Indications for pacing in multifascicular block Pacemaker necessary Pacemaker probably necessary Pacemaker not necessary Symptomatic patients with fascicular block and significantly prolonged H-V interval by electrophysiologic study Patients with syncope and bifascicular or trifascicular block with other etiologies of syncope excluded Asymptomatic fascicular block without AV block Symptomatic patients with block distal to His at atrial paced rates of less than 100-120 bpm Pacing-induced block distal to His at atrial paced rates of less than 130 bpm Asymptomatic fascicular block and first degree AV block Symptomatic patients with bifascicular block and intermittent type II second degree AV block or third degree AV block Asymptomatic patients with fascicular block and intermittent type II second degree or third degree AV block

©2013 UpToDate ® Print Email ACC/AHA/HRS guideline summary: Indications for permanent pacing in chronic bifascicular block Class I - There is evidence and/or general agreement that permanent pacing is indicated in patients with chronic bifascicular block in the following settings: • Advanced second-degree AV block or intermittent third-degree AV block. (Level of Evidence: B) • Type II second-degree AV block. (Level of Evidence: B) • Alternating bundle branch block. (Level of Evidence: C) Class IIa - The weight of evidence or opinion is in favor of the usefulness of permanent pacing in patients with chronic bifascicular block in the following settings: • Syncope not demonstrated to be due to AV block when other likely causes have been excluded, specifically ventricular tachycardia (VT). (Level of Evidence: B) • Incidental finding at electrophysiological study of a markedly prolonged HV interval (≥100 msec) in asymptomatic patients. (Level of Evidence: B) • Incidental finding at electrophysiological study of pacing-induced infra-His block that is not physiological. (Level of Evidence: B) Class IIb - The weight of evidence or opinion is less well established for the usefulness of permanent pacing in patients with chronic bifascicular block in the following setting: • Neuromuscular diseases, such as myotonic muscular dystrophy, Erb dystrophy (limb-girdle muscular dystrophy), and peroneal muscular atrophy with bifascicular block or any fascicular block, with or without symptoms. (Level of Evidence: C) Class III - There is evidence and/or general agreement that permanent pacing for chronic bifascicular block is not useful in in the following settings: • Fascicular block without AV block or symptoms. (Level of Evidence: B) • Fascicular block with first-degree AV block without 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.