Permanent Pacemakers (PPM), Implantable Cardioverter-Defibrillator ...
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Description

Permanent Pacemakers (PPM), Implantable Cardioverter-Defibrillator (ICD) and Cardiac Resynchronization Therapy (CRT) Placement Indications

Class I PPM Indications: below are highlights of most important indications.

Sinus Node Dysfunction:

 ▪ Symptomatic sinus bradycardia (± sinus pauses) or chronotropic incompetence

 ▪ Symptomatic medication-induced bradycardia if medication (i.e., BB) is required for underlying medical condition

AV Block (AVB)/Conduction Disease:

 ▪ Symptomatic 2° AVB or 3°AVB

 ▪ Asymptomatic Mobitz II 2° AVB or 3° AVB with: asystole ≥ 3 sec (>5 seconds if in AF), escape rate ≤ 40 BPM (or >40 BPM if cardiomegaly also present), or wide-complex escape rhythm

 ▪ Permanent Mobitz II 2° AVB or intermittent 3° AVB (regardless of symptoms)

 ▪ Alternating bundle branch block

Neurocardiogenic:

 ▪ Recurrent syncope AND inducible asystole ≥ 3 sec with carotid massage

Class I ICD Indications: ↓mortality vs. optimal medical therapy (OMT); guidelines apply only to pts who meet eligibility while on OMT

Primary Prevention:

 - iCM with EF ≤ 35% at least 40d s/p MI + NYHA Class II/III

 - iCM with EF ≤ 30% at least 40d s/p MI + NYHA Class I

 - Non-ischemic dCM with EF ≤ 35% + NYHA Class II/III*

 - iCM with EF ≤ 40% at least 40d s/p MI + NSVT + inducible VT/VF on EP study

 - Unexplained syncope w/ hemodynamically significant inducible VT/VF on EP study

Secondary Prevention:

 - Prior episode of cardiac arrest (VF/pulseless VT) or sustained unstable VT if no reversible cause found

- Structural heart disease with spontaneous sustained VT (stable or unstable)

ACA/AHA/HRS 2012 CRT Indications: ↓mortality vs. OMT

Class I:

 • NYHA I - none

 • NYHA II - LVEF ≤ 35%, QRS ≥ 150ms, LBBB, & sinus rhythm

 • NYHA III / NYHA IV- LVEF ≤ 35%, QRS ≥ 150ms, LBBB, & sinus rhythm

Class IIa:

 • NYHA I - none

 • NYHA II- LVEF ≤ 35%, QRS 120-149ms, LBBB, and sinus rhythm

 • NYHA III / NYHA IV

      - LVEF ≤ 35%, QRS 120-149ms, LBBB, & sinus rhythm

      - LVEF ≤ 35%, QRS ≥ 150ms, & non-LBBB

Class IIb:

 • NYHA I - LVEF ≤ 30%, QRS ≥ 150ms, LBBB, & iCM

 • NYHA II - LVEF ≤ 35%, QRS ≥ 150ms, nonLBBB pattern, & sinus rhythm

 • NYHA III / NYHA IV - LVEF ≤ 35%, QRS 120-149ms, non-LBBB pattern, & sinus rhythm



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MGH White Book Manual
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Account created for the MGH Internal Medicine Housestaff Manual "White Book" - https://stk10.github.io/MGH-Docs/WhiteBook-2019-2020.pdf
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