NASPE Pacing & ICD Indications AHA Update 2002

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1 NASPE Pacing & ICD Indications AHA Update 2002 Lauren Butler Cardiac Physiologist Training and Development Manager

2 CLASS I Conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful and effective

3 CLASS II Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment CLASS IIA Weight of evidence/opinion is in favor of usefulness/efficacy CLASS IIB Usefulness/efficacy is less well established by evidence/opinion

4 CLASS III Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful

5 AV BLOCK (acquired) CLASS I (1) 3 and advanced 2 associated with:- - Bradycardia - Arrhythmias - Asystole 3 Seconds - Post AVN Abl - Post OHS - Neuromuscular Disease (2) 2 AV Block and Bradycardia

6 AV BLOCK (acquired) (1) Asymptomatic 3 - LV Dysfunction - Cardiomegaly CLASS IIa (2) Asymptomatic type II, narrow QRS (wide=class I) (3) Asymptomatic Type I Intra/infra HIS (4) Symptomatic 1 or 2

7 AV BLOCK (acquired) CLASS IIb 1 & LV dysfunction or Heart Failure Neuromuscular Disease and any type block

8 AV BLOCK (acquired) CLASS III (1) Asymptomatic 1 (2) Asymptomatic Type I at supra HIS (3) AV Block that is expected to resolve

9 CHRONIC BIFASCICULAR AND TRIFASCICULAR BLOCK CLASS I (1) Intermittent 3 AV Block (2) Type II 2 AV Block (3) Alternating bundle-branch block

10 CHRONIC BIFASCICULAR AND TRIFASCICULAR BLOCK CLASS IIa (1) Syncope (not demonstrated to be due to AV Block) but other causes excluded (2) HV interval > 100 milliseconds (3) Pacing induced infra-his block

11 CHRONIC BIFASCICULAR AND TRIFASCICULAR BLOCK CLASS IIb (1) Neuromuscular Disease and any type fascicular block

12 CHRONIC BIFASCICULAR AND TRIFASCICULAR BLOCK CLASS III (1) Asymptomatic fascicular block (Bi & Tri)

13 SINUS NODE DYSFUNCTION CLASS I S N Dysfunction & Bradycardia Symptomatic Chronotropic incompetence

14 SINUS NODE DYSFUNCTION CLASS IIa S N Dysfunction & Bradycardia (symptoms not linked) Syncope & S N abnormalities at EPS

15 SINUS NODE DYSFUNCTION CLASS IIb Minimal symptomatic patient - S R < 40bpm

16 SINUS NODE DYSFUNCTION CLASS III (1) Asymptomatic S N dysfunction (2) Symptoms and S N dysfunction (not linked, documented) (3) Symptomatic S N dysfunction - non essential drug therapy

17 PREVENTION AND TERMINATION OF TACHYARRHYTHMIAS PACING CLASS I (1) Pause dependent VT

18 PREVENTION AND TERMINATION OF TACHYARRHYTHMIAS PACING CLASS IIa (1) High risk Congenital long QT

19 PREVENTION AND TERMINATION OF TACHYARRHYTHMIAS PACING CLASS IIb (1) AVRT/AVNRT unable to treat medical or ablative therapy (2) Prevention AF and S N dysfunction

20 PREVENTION AND TERMINATION OF TACHYARRHYTHMIAS PACING CLASS III (1) Ventricular Ectopic activity (2) Long QT with reversible cause (Torsade de Pointes)

21 CAROTID SINUS SYNDROME & NEUROCARDIOGENIC SYNCOPE CLASS I (1) CSS Massage > 3 seconds

22 CAROTID SINUS SYNDROME & NEUROCARDIOGENIC SYNCOPE CLASS IIa (1) Syncope & hypersensitive Cardioinhibitory response (unclear mechanism) (2) Bradycardia at positive tilt

23 CAROTID SINUS SYNDROME & NEUROCARDIOGENIC SYNCOPE CLASS III (1) Asymptomatic CS Massage or vague symptoms (2) Syncope no cardioinhibitory response (3) Situational syncope can be avoided

24 HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY(HOCM) CLASS IIb (1) Symptomatic HOCM with resting or provoked significant gradient

25 HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY(HOCM) CLASS III (1) Asymptomatic HOCM (2) Symptomatic no evidence LV outflow obstruction

26 DILATED CARDIOMYOPATHY CLASS IIa Bivent Pacing NYHA class III or IV - QRS >130 milliseconds -EF < 35%

27 DILATED CARDIOMYOPATHY CLASS III (1) Asymptomatic dilated cardiomyopathy (2) Symptomatic Ischemia can be revascularised

28 POST TRANSPLANTATION CLASS I (1) Symptomatic Bradycardia/Chronotropic incompetence - not expected to resolve

29 POST TRANSPLANTATION CLASS IIb (1) Symptomatic Bradycardia/Chronotropic incompetence - may last months

30 POST TRANSPLANTATION CLASS III (1) Asymptomatic Bradycardia

31 ICD INDICATIONS CLASS I (1) Cardiac arrest due to VT/VF - no reversible cause (2) Spontaneous sustained Structural Heart Disease (3) Syncope & positive VT study - drugs not tolerated or preferred (4) Nonsustained & CAD, post MI, poor LV, 35%, positive EPS (no drugs) (5) Sustained VT no structural heart disease - not amenable to other treatments

32 ICD INDICATIONS CLASS IIa (1) LV ejection fraction 30% (1 month post MI, 3 months post OHS)

33 ICD INDICATIONS CLASS IIb (1) Cardiac arrest presumed VF when unable to perform EPS (2) Severe symptoms attributable to ventricular tacharrhythmia awaiting cardiac transfer (3) Familial conditions high risk sudden cardiac death eg long QT, HOCM (4) Nonsustained VT & CAD post MI, poor LV, positive EPS

34 ICD INDICATIONS CLASS IIb (5) Syncope of undetermined origin + poor LV + positive EPS (6) Syncope or family history sudden cardiac death + brugada ECG changes (7) Syncope, heart disease - unable to find cause (structural heart disease)

35 ICD INDICATIONS CLASS III Syncope negative EPS no structrual heart disease Incessant VT/VF VT/VF due to ablatable arrhythmias VT due to transient or reversible cause Psychiatric illness may be aggrevated by ICD implant or preclude follow up

36 ICD INDICATIONS CLASS III (6) Terminal illness <6 months (7) CAD, poor LV, Wide QRS - undergoing coronary bypass surgery (8) NYHA IV heart failure - not candidates for cardiac transplantation