ESC Guidelines for Pacing, g CRT and ICDs

ESC/EHRA Pacing Guidelines ESC guidelines cover two main areas: the firstincludes permanent pacing in bradyarrhythmias,syncope and other specific conditions, while thesecond refers to ventricular resynchronization asan adjunct therapy in patients with HF.ESC/EHRA pacing guidelinesAppendices Theguidelineshavebeenenrichedwithihtwoappendices that refer not only to conventionalpacemakerfollow-upbut alsototechnicalconsiderations and requirements for implantingand follow-upof CRT devices.

Sinus node diseaseRecommendations for cardiac pacing in SNDConventional indications for pacingThe ESC/EHRA 2007 Guidelines present detailed definitions follow anup-toto-datepatients with syncope.approachtotheevaluationof take into consideration the results of recent trials (MOST,CTOPP, PASE, DAVID etc) and the technological advances,providing• level of evidence in mode selection.• recommendations fortheuseofnew algorithms(MPV,ANTITACHY)

Recommendations for cardiac pacingin carotid sinus syndromeRecommendations for cardiac pacing in VVS(ESC/EHRA 2007 GLs)

Conventional indications for pacingThe ESC/EHRA 2007 Guidelines present detailed definitions follow anup-toto-datepatients with syncope.approachtotheevaluationof take into consideration the results of recent trials (MOST,CTOPP, PASE, DAVID etc) and the technological advances,providing• level of evidence in mode selection.• recommendations fortheuseofnew algorithms(MPV,ANTITACHY)Pacemaker mode selectionin sinus node disease

Cardiac Resynchronization TherapyThe ESC/EHRA 2007 GLs From atheoreticalpoint of view it may be moreappropriate to target mechanical dyssynchrony,rather than electrical conduction delay. However,theexistenceofmechanicaldyssynchrony in HF has not yet been establishedas a patient t selection ect criterion for CRT.Cardiac Resynchronization TherapyCriteria for patient selectionEchocardiographic criteria for CRTTen years of research in the field of dyssynchrony inechocardiography have resulted in two negative studieswhich have, to some extent, discredited the method:PROSPECTRETHINQ

ESC / EHRA Guidelines for Cardiac Pacingand dC Cardiac Resynchronization i TherapyESC Guidelines for Cardiac Pacing and Resynchronization Therapy 2007 (EHJ 2007)Recommendation e o for the use of cardiac ac resynchronizationotherapy by CRT-P and CRT-D in HF patientsHeart failure patients, who remain symptomatic in NYHA classes III –IV, despite optimal medical therapy, with:• LVEF < 35 %• LV dilatation• QRS complex > 120 ms• Normal sinus rhythm• Class I, level of evidenceAforCRT-P to reduce morbidityand mortality.CRT-D is an acceptable option for patients who haveexpectancy of survival > 1 yearESC / EHRA Guidelines for Cardiac pacingand dC Cardiac Resynchronization i TherapyESC Guidelines for Cardiac Pacing and Resynchronization Therapy 2007 (EHJ 2007)Recommendations for the use of an ICD combined withbiventricular pacemaker (CRT-D) in heart failure patients withan indication for an ICDHeart failure patients with a Class I Indication for an ICD with:• Symptoms in NYHA classes III –IVdespite OPT• LVEF < 35 %• LV dilatation• QRS complex > 120 ms• In Sinus RhythmClass I, Level of evidence B

ESC / EHRA Guidelines for Cardiac pacingand dC Cardiac Resynchronization i TherapyESC Guidelines for Cardiac Pacing and Resynchronization Therapy 2007 (EHJ 2007)Recommendations for the use of biventricular pacing in heartfailure patients with permanent AFHeart failure patients who remain symptomatic in NYHAclasses III – IV despite OPT, with:• Low LVEF

Open Issues for CRT implantation Patient selection criteria• Electrical or mechanical asynchrony Mild heart failure No heart failure• Pacemaker dependent d patientst• Patients with dyssynchronyOpen Issues for CRT implantationSpecial group of patientsCRT in patients with mild heart failureCan an early intervention with CRT slow the progression ofheart failure? REVERSE(ResynchronizationReversesRemodelinginSystolic Left Ventricular Dysfunction) study has shown thatimplanting these devices in class I and II patients, shows acomparable benefit to what we saw in class III and IVpatients. There was about a 50% reduction in hospitalizations for HFand overall patients did very well with that therapy.Linde, C. J Am Coll Cardiol 2008; 52:1834–43

Open Issues for CRT implantationSpecial group of patientsCRT in patients with mild heart failureMADIT-CRT In high risk, asymptomatic or mildly symptomatic,NYHA Class I and II patients, LVEF ≤0.30, and QRSduration ≥130 ms, CRT-Ds associated with asignificant 29% reduction (p=0.003) in death or heartfailure interventions when compared to traditional ICDs. Early use of CRT in milder heart failure patients mightbe beneficial in improving LV function, leading to areduction in symptoms, hospitalizations, and mortality.Moss AJ, N Engl J Med 2009; 361:1329–38.Open Issues for CRT implantationUpdated d GuidelinesHas the time come for an update of the existingguidelines?It is clear that the findings of the REVERSE study and of somesub-studies (eg the Wide QRS arm) as well as the MADIT-CRT trial indicate the need to alter sections of the existingGuidelines.Especially for patients with mild heart failure, it is veryprobable bl that t recommendations will be changed in theupdate of the Guidelines.

Conclusions The publishedESCGuidelines,basedon thelatestscientificevidencecontributetib t totheimprovedmanagement of pacemaker, CRT, ICD candidates. Undoubtedly, the rapid advances in our scientific fieldrequire the frequent updating of such GLs to include allthe facts that are important for contemporary evidence-based medicine. An important target is the implementation of ESC/EHRAGuidelines.