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Guidelines Flashcards

1
Q

Is asymptomatic sinus bradycardia an indication for a pacemaker?

A

Sinus bradycardia is only an indication for pacing if the patient is symptomatic.

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2
Q

What class recommendation is SND with clear symptom correlation in the ESC guidelines?

A

Class I recommendation

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3
Q

What class recommendation is SND with symptoms likely due to bradycardia, even if the evidence is not conclusive in the ESC guidelines?

A

Class IIb recommendation

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4
Q

What class recommendation is asymptomatic sinus bradycardia or due to reversible causes? (ESC guidelines)

A

Class III - pacing is not recommended

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5
Q

Can AV block be an indication for pacemaker implant in asymptomatic patients?

A

Yes

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6
Q

What is the Class I indication for AV block according to ESC guidelines?

A

Pacing is indicated in patients with 3rd degree AV block or 2nd degree type 2 AV block regardless of patient symptoms.

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7
Q

What is the Class II indication for AV block according to ESC guidelines?

A

Pacing should be considered in patients with 2nd degree type 1 AV block who are symptomatic or found to have intra- or infra-hisian AV block on EPS.

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8
Q

What is the Class III indication for AV block according to ESC guidelines?

A

Pacing is not indicated in patients with AV block which is due to reversible causes.

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9
Q

Whats is the Class I indication for pacing in patients with intermittent documented bradycardia due to SND according to ESC guidelines?

A

Pacing is indicated in patients who are affected by SND with documented symptomatic bradycardia due to sinus arrest or sinus-atrial block (including tachy-brady form).

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10
Q

What is the Class III indication for pacing in patients with intermittent documented bradycardia due to SND according to ESC guidelines?

A

Pacing is not indicated in reversible causes of bradycardia.

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11
Q

What is the Class I indication for pacing for patients with documented bradycardia due to intermittent AV block according to ESC guidelines?

A

Pacing is indicated for intermittent/ paroxysmal intrinsic 3rd or 2nd degree AV block (including AF with slow ventricular response).

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12
Q

What is the Class III indication for pacing for patients with documented bradycardia due to intermittent AV block according to ESC guidelines?

A

Pacing is not indicated in reversible causes of bradycardia.

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13
Q

What is the class recommendation for reflex asystolic syncope according to ESC guidelines and what is the recommendation?

A

It is Class IIa - pacing should be considered for patients >= 40 yrs with recurrent, unpredictable reflex syncopes and documented symptomatic pause/s due to sinus arrest or AV block or the combination of the two.

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14
Q

What is the ESC guidelines recommendation for asymptomatic pauses (sinus arrest or AV block)?

A

Class IIa recommendation - Pacing should be considered in patients with history of syncope and documentations of asymptomatic pauses >6 s due to sinus arrest, sinus-atrial block or AV block.

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15
Q

What is the 1st choice pacing mode for persistent SND and no chronotropic incompetence? What is the 2nd choice?

A

1st choice: DDD + AVM (AVM = AV delay management)
2nd choice: AAI

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16
Q

What is the 1st choice of pacing mode for persistent SND with chronotropic incompetence? What is the 2nd choice?

A

1st choice: DDDR + AVM (AVM = AV delay management)
2nd choice: AAIR

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17
Q

What is the 1st choice of pacing mode for intermittent SND? What are the 2nd and 3rd choices?

A

1st choice: DDDR + AVM (AVM= AV delay management)
2nd choice: DDDR, no AVM
3rd choice: AAIR

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18
Q

What is the 1st choice of pacing mode for patients with persistent AV block? What are the 2nd and 3rd choices?

A

If patient has concomitant SND: 1st choice: DDDR; 2nd choice: DDD, 3rd choice: VVIR
If patient doesn´t have concomitant SND: 1st choice: DDD, 2nd choice: VDD, 3rd choice: VVIR
If patient in persistent AF: 1st choice: VVIR

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19
Q

What is the 1st choice of pacing mode for patients with intermittent AV block?

A

DDD+AVM (AVM= AV delay management)
If AF: VVIR

20
Q

What are the Class I recommendation for BBB?

A

Pacing is indicated for patients with alternating BBB with or without symptoms.
Pacing is indicated for patients with syncope, BBB and positive EPS defines as HV interval >70 ms, or 2nd or 3rd degree His-Purkinje block, demonstrated during incremental atrial pacing or with pharmacological challenge.

21
Q

What is the pacing indication for patients with HCM?

A

Dual chamber pacemaker or dual chamber ICD with sequential AV pacing with short AV delay may be considered (Class IIb) in selected patients with resting or provocable LV outflow tract obstruction and drug-refractory symptoms who:
a. Have contraindication for septal alcohol ablation or septal myectomy
or
b. Are at high risk of developing heart block following septal ablation or myectomy

22
Q

What type of device should be considered in patient with HCM and indication for ICD?

A

A dual-chamber ICD device should be considered with sequential AV pacing with short AV delay.

23
Q

What is the Class I pacing recommendation for patients with undocumented reflex syncope according to ESC guidelines?

A

Pacing is indicated in patients with dominant cardioinhibitory carotid sinus syndrome and recurrent unpredictable syncope. Dual-chamber pacing is the preferred mode of pacing.

24
Q

What is the Class IIb recommendation for patients with undocumented reflex syncope according to ESC guidelines?

A

Pacing may be indicated in patients with tilt-test inducted cardioinhibitory carotid response with recurrent frequent unpredictable syncope and age >40 years after alternative therapy failed. Dual-chamber pacing is the preferred mode of pacing.

25
Q

What is the recommendation for AV block in context of acute myocardial infarction?

A

AV block complicating acute myocardial infarction most often resolves itself spontaneously within 2-7 days. Permanent pacing does not influence the prognosis of these patients, therefore it is not recommended.

26
Q

What is the recommendation for cardiac pacing following cardiac surgery/ TAVI?

A
  1. Pacing is indicated if high degree or complete AV block does not resolve following 7 days observation period following cardiac surgery or TAVI. However in cases of complete AV block with low rate escape rhythm this observation period can be shortened since resolution is unlikely.
  2. Pacing is indicated if sinus node dysfunction does not resolve following 5 days up to some weeks of observation period post cardiac surgery or heart transplantation.
27
Q

What is the indication for cardiac pacing in patients with chronotropic incompetence after heart transplantation?

A

Class IIb - pacing should be considered for chronotropic incompetence impacting quality of life in the post transplantation period.

28
Q

What are the Class I recommendations for pacing in children and congenital heart disease?

A

Pacing is indicated in high degree or complete AV block in symptomatic patients and in asymptomatic patients with any of the following risk conditions: ventricular dysfunction, prolonged QTc, complex ventricular ectopy, wide range QRS escape rhythm, ventricular rate < 50 bpm, ventricular pauses > three-fold the cycle length of the underlying rhythm.

Pacing is indicated for postoperative congenital heart disease for 2nd degree and complete AV block persisting > 10 days.

Pacing is indicated for symptomatic SND, including tachy-brady syndrome, when there is correlation with symptoms.

29
Q

In what congenital defects epicardial lead are considered?

A

Congenital defects with right-to-felt shunts. Postoperative absence of transvenous access to the target chamber.
In children is preferable to postpone endocardial pacing to minimize the risk associated with the presence of multiple intracardiac leads. Higher risk of lead abandonment, potential valvular injury and vascular crowding. Children´s higher activity levels lead to greater stress on device hardware and their growth expectancy leads to higher incidence of lead dislodgement or fracture.

30
Q

What are the indications for pacemaker implantation in pregnant females with congenital heart disease?

A

Women who exhibit CHB with slow, wide QRS escape rhythm should undergo PM implantation during pregnancy. A PM for the alleviation of symptomatic bradycardia can be implanted at any stage during pregnancy using echo guidance or electro-anatomic navigation avoiding fluoroscopy.

31
Q

What are the recommendations for marked 1st degree AV block?

A

Permanent cardiac pacing should be considered for patients with persistent symptoms similar to those of pacemaker syndrome attributable to marked 1st degree AV block (Class IIa).

32
Q

What is pacemaker syndrome?

A

Pacemaker syndrome results from an ineffective or decreased contribution of the atrial systole to the cardiac output. There is shortening of the LV filling time and diastolic mitral regurgitation. As a consequence, there is an increase in the pulmonary capillary wedge pressure with resulting increased retrograde blood flow in the jugular veins and dyspnoea. Increased jugular vein pressure are described as a sensation of fullness in the neck. The deleterious effects are more marked in patients with impaired LV function and HF.

33
Q

What are the SCD primary prevention indications for ICD implantation?

A

Cardiomyopathy:
a. Ischaemic: EF<=30%, NYHA I-III and at leas t >40 days post-MI; EF<=35%, NYHAII-III and at least >40 days post-MI; EF<=40%, non-sustained VT and inducible for VF or VT during EPS
b. Non-ischaemic: EF<=35% and NYHA I-III
c. Hypertrophic cardiomyopathy or arrhythmogenic RV dysplasia: risk factors for sudden death

Channelopathy: Brugada syndrome, long QT syndrome, catecholaminergic polymorphic VT: cardiac arrest, VT, syncope, or other high-risk features

34
Q

What large trials have provided data on the prevention of SCD by an ICD?

A
  • DINAMIT: The Defibrillator in Acute Myocardial Infarction Trial
  • MADIT I and II (Multicentre Automatic Defibrillator Implantation Trial) - “Implantable defibrillators (ICDs) have demonstrated a 31% mortality reduction for patients with history of CAD / MI and EF ≤ 30% (Madit II study, Moss et al., NEJM 2002).”
  • MUSTT (Multicentre Unsustained Tachycardia Trial)
  • SCD-HeFT trial (Sudden Cardiac Death in Heart Failure Trial)
35
Q

What are the recommendations for ICD implantation for secondary prevention of SCD and VT?

A

ICD implantation is recommended in patients with documented VF or haemodynamically not tolerated VT in the absence of reversible causes or within 48 hr after myocardial infarction who are receiving chronic optimal medical therapy and have a reasonable expectation of survival with a good functional status >1 year.

36
Q

What are the SCD secondary prevention indications for ICD implantation?

A

Survivor of cardiac arrest:
a. Reversible cause (e.g. acute MI, hyperkalemia) - ICD not indicated
b. No reversible causes - ICD indicated

Sustained VT:
a. Structural heart disease - ICD inidicated
b. No structural heart disease + syncope haemodynamically unstable VT - ?inidcated/ not indicated

37
Q

What is the indication for ICD in patients with recurrent sustained VT?

A

Class IIa recommendation - ICD implantation is recommended in patients with recurrent sustained VT when not within 48 hr after MI and who are receiving optimal medial therapy, have a normal LVEF and have a reasonable expectation of survival with good functional status >1 yr.

38
Q

When is amiodarone indicated for patients with ICD indication for VF/VT?

A

In patients with VT/VF and indication for ICD, amiodarone may be considered if ICD is not available, contraindicated for concurrent reasons or refused by the patient (Class IIb).

39
Q

What are the S-ICD indications?

A

Class IIa - S-ICD should be considered as an alternative to transvenous ICD in patients with indication for an ICD when pacing for bradycardia support, cardiac resynchronisation or ATP is not needed.

Class IIb - S-ICD may be considered as an alternative to transvenous ICD when venous access is difficult, after the removal of a tranvenous ICD for infections, or in young patients with a long term need for an ICD.

40
Q

What are the CRT indications according to ESC guidelines?

A

CRT is indicated in patients with symptomatic HF in SR with LBBB and QRS duration >130 msec and LVEF <= 35% (Class I)

CRT may be considered in patients with symptomatic HF in SR with QRS duration >130 msec but non-LBBB QRS morphology and LVEF <=35% (Class II)

CRT is indicated in patients with symptomatic HF with LVEF <=35% and an indication for ventricular pacing and high degree AV block (2nd/3rd degree) in order to reduce morbidity (includes patients with AF) (Class I)

CRT is not indicated in patients with QRS duration <130 msec (Class III)

41
Q

What are the CRT recommendations for patients with HF according to ESC guidelines?

A

CRT is recommended for symptomatic patients with HF in sinus rhythm with a QRS duration >150 msec and LBBB, LVEF <=35% despite OMT in order to improve symptoms and reduce morbidity and mortality.

CRT is recommended for patients with symptomatic HF in sinus rhythm a QRS duration 130-149 msec and LBBB QRS morphology, and with LVEF <=35% despite OMT in order to improve symptoms and reduce morbidity and mortality.

CRT rather than RV pacing is recommended for patients with HFrEF regardless NYHA class who have an indication for ventricular pacing and high degree AV block in order to reduce morbidity. This includes patients with AF.

42
Q

CRT-P or CRT-D? How to choose between the two?

A

If a patient is scheduled to receive an ICD and is in sinus rhythm with a QRS duration ≥130 ms:

    CRT-D should be considered if the QRS is between 130 and 149 ms

    CRT-D is recommended if the QRS is ≥150 ms

If the primary reason for implanting CRT is to improve prognosis, then the majority of evidence lies with CRT-D for patients in NYHA Class II and CRT-P for patients in NYHA Classes III-IV.

43
Q

Name class I indications for lead removal

A
  • Sepsis
  • Life threatening arrhythmia secondary to a retained lead fragment
  • Retained lead or fragment that poses an immediate physical threat
  • Clinically significant thromboembolic events caused by a retained lead or fragment
  • Obliteration or occlusion of of all usable veins with the need to implant a new pacing system
  • Lead that interferes with the operation of another implantable device
44
Q

Name class II indications for lead removal

A
  • Localised pocket infection, erosion, or drained sinus that does not involve the transvenous part of the lead system when the lead can be cut through in a clean cut that is completely separate from the infected area
  • Occult infection for which no cause can be found and for which the pacing system is suspected
  • Chronic lead insertion site or pocket pain that causes significant discomfort and is not manageable by surgical or medical techniques
  • Lead that poses a potential but not immediate threat to the patient because of lead design failure
  • Lead that interferes with treatment of malignancy
  • Leads that interfere with venous access for newly required implantable devices
  • Redundant leads in young patients
  • Traumatic lead entry site that may interfere with reconstruction of the site
45
Q

Name class III indications for lead removal

A
  • Single non-functional lead in older patient
  • Risk posed by removal outweighs the benefits
  • Normally functioning lead that can be reused at PG replacement providing it´s in good condition

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