Indications for Permanent Pacemakers 

Sinus node dysfunction†

Symptomatic bradycardia with symptoms directly correlated to bradycardia

Symptomatic bradycardia due to essential medications (alternatives contraindicated)

Symptomatic bradycardia in patients with tachy-brady syndrome and symptoms attributable to bradycardia

Symptomatic chronotropic incompetence (heart rate cannot meet physiologic demands)

—

Asymptomatic bradycardia

Symptoms consistent with bradycardia but clearly shown not to be associated with it

Symptomatic bradycardia due to nonessential medications

Sleep-related bradycardia

AV block†

Any acquired high-grade, third-degree, or second-degree type II AV block regardless of symptoms and that is not attributable to reversible or physiologic causes

Symptomatic AV block that does not resolve despite treatment of potential causes

Third-degree or second-degree AV block, or HV interval of ≥ 70 milliseconds in patients with neuromuscular diseases associated with conduction abnormalities (eg, myotonic dystrophy) regardless of symptoms

Symptomatic bradycardia in patients with atrial fibrillation

Symptomatic AV block due to essential medications which cannot be discontinued

Second-degree type II, third-degree, or high-grade AV block in patients with an infiltrative cardiomyopathy (eg cardiac sarcoidosis or amyloidosis) and life expectancy > 1 year

PR interval > 240 milliseconds and left bundle branch block in patients with lamin A/C gene mutations (including limb-girdle and Emery Dreifuss muscular dystrophies) and life expectancy > 1 year

First-degree or second-degree type I AV block with symptoms that are clearly attributable to the AV block

Symptomatic second-degree or third-degree AV block due to due to thyroid function abnormalities without observing for reversibility

PR interval > 240 milliseconds, QRS duration > 120 milliseconds, or fascicular block, in patients with neuromuscular diseases associated with conduction abnormalities (eg, myotonic dystrophy) if life expectancy > 1 year

First-degree AV block, type I second-degree AV block or 2:1 AV block at the AV node level in patients who are asymptomatic

First-degree AV block, type I second-degree AV block or 2:1 AV block at the AV node level in patients with symptoms that are not attributable to the AV block

AV block expected to resolve or unlikely to recur (eg, due to medication toxicity or Lyme disease or occurring asymptomatically during transient increases in vagal tone)

Tachyarrhythmias‡

Sustained, pause-dependent VT (including torsades de pointe VT)

High-risk patients with congenital long QT syndrome

Symptomatic recurrent SVT reproducibly terminated by pacing when ablation and/or medications fail (except when there is an accessory AV connection capable of high-frequency antegrade conduction)

Prevention of symptomatic, recurrent atrial fibrillation refractory to medications when sinus node dysfunction coexists

Frequent or complex ventricular ectopy without sustained VT when long QT syndrome is absent

Torsades de pointes VT with reversible causes

Prevention of AF in patients without another indication for pacing

After acute myocardial infarction†

Persistent second-degree type II, high-grade or third-degree AV block

None

None

Transient AV block

Acquired BBB or fascicular block without second- or third-degree AV block

Fascicular and bundle branch block†

Syncope in patients with an HV interval of ≥ 70 millisecond or evidence of infranodal block at electrophysiology study

Alternating BBB

Fascicular block and BBB in patients with Kearns-Sayre syndrome if life expectancy is > 1 year

QRS prolongation > 110 milliseconds in patients with Anderson-Fabry disease

In patients with heart failure and LVEF 36–50% and LBBB (QRS ≥ 150 milliseconds) as part of CRT if life expectancy is > 1 year

Fascicular and bundle branch block with 1:1 AV conduction in asymptomatic patients

Congenital heart disease‡

Advanced second- or third-degree AV block causing symptomatic bradycardia, ventricular dysfunction, or low cardiac output

Sinus node dysfunction correlated with symptoms during age-inappropriate bradycardia

Postoperative high-grade second- or third-degree AV block that is not expected to resolve or that persists ≥ 7 days after surgery

Congenital third-degree AV block with a wide QRS escape rhythm, complex ventricular ectopy, or ventricular dysfunction

Congenital third-degree AV block in infants with a ventricular rate of < 55 beats/minute or with a congenital heart disease and a ventricular rate of < 70 beats/minute

Sustained pause-dependent VT, with or without prolonged QT, when pacing has been documented as effective

Congenital heart disease and sinus bradycardia to prevent recurrent episodes of intra-atrial reentrant tachycardia

Congenital third-degree AV block persisting after age 1 year if average heart rate is < 50 beats/minute, ventricular rate pauses abruptly for 2 or 3 times the basic cycle length, or symptoms due to chronotropic incompetence occur

Asymptomatic sinus bradycardia in children with a complex congenital heart disease and resting heart rate of < 40 beats/minute or pauses in ventricular rate of > 3 seconds

Patients with a congenital heart disease and impaired hemodynamics due to sinus bradycardia or loss of AV synchrony

Unexplained syncope in patients who have had congenital heart disease surgery that was complicated by transient third-degree AV block with residual fascicular block

Transient postoperative third-degree AV block that converts to sinus rhythm with residual bifascicular block

Congenital third-degree AV block in asymptomatic infants, children, adolescents, or young adults with an acceptable ventricular rate, a narrow QRS complex, and normal ventricular function

Asymptomatic sinus bradycardia after biventricular repair of a congenital heart disease and resting heart rate of < 40 beats/minute or pauses in ventricular rate of > 3 seconds

Transient postoperative AV block when AV conduction returns to normal

Asymptomatic postoperative bifascicular block with or without first-degree AV block and without prior transient third-degree AV block

Asymptomatic type I second-degree AV block

Asymptomatic sinus bradycardia when the longest RR interval is < 3 seconds and minimum heart rate is > 40 beats/minute

Hypersensitive carotid sinus syndrome and neurocardiogenic syncope‡

Recurrent syncope due to spontaneously occurring carotid sinus stimulation or to carotid sinus pressure that induces asystole of > 3 seconds

Recurrent syncope without obvious triggering events and with a hypersensitive cardioinhibitory response (ie, carotid sinus pressure induces asystole of > 3 seconds)

Significantly symptomatic neurocardiogenic syncope associated with bradycardia documented clinically or during tilt-table testing

Hyperactive cardioinhibitory response to carotid sinus stimulation without symptoms or with vague symptoms (eg, dizziness, light-headedness)

Situational vasovagal syncope that can be averted by avoidance

Post cardiac transplantation‡

Inappropriate or symptomatic bradycardia that is persistent or expected to persist

Other established indications for permanent pacing

None

Prolonged or recurrent relative bradycardia limiting rehabilitation or discharge after postoperative recovery

Syncope after transplantation even when bradyarrhythmia has not been demonstrated

None

Hypertrophic cardiomyopathy‡

Same as established indications for sinus node dysfunction or AV block

None

Medically refractory symptomatic patients with significant resting or provoked LV outflow tract obstruction

Asymptomatic or medically controlled hypertrophic cardiomyopathy

Symptomatic hypertrophic cardiomyopathy with no evidence of LV outflow obstruction

Cardiac resynchronization therapy for patients with heart failure with reduced ejection fraction‡

CRT (with or without an ICD) for patients with LVEF ≤ 35%, LBBB, QRS duration ≥ 0.15 second, sinus rhythm, and NYHA class II, class III, or ambulatory class IV heart failure symptoms during optimal medical therapy

CRT (with or without an ICD) for patients with LVEF ≤ 35%, sinus rhythm, LBBB, QRS duration 0.12–0.149 second, and NYHA class II, class III, or ambulatory class IV heart failure symptoms during optimal medical therapy

CRT for patients with LVEF ≤ 35%, sinus rhythm, non-LBBB, QRS duration ≥ 0.15 second, and NYHA class II, class III, or ambulatory class IV heart failure symptoms during optimal medical therapy

CRT for patients with LVEF ≤ 35% in AF who otherwise meet criteria for CRT, and AV node ablation or pharmacologic therapy will allow near 100% ventricular pacing

CRT for patients with LVEF ≤ 35% who are undergoing new or replacement device with anticipated > 40% ventricular pacing

LVEF ≤ 30% caused by ischemic heart disease) in sinus rhythm, QRS duration ≥ 0.15 second, and NYHA class I heart failure symptoms during optimal medical therapy

LVEF ≤ 35%, sinus rhythm, non-LBBB, QRS duration 0.12–0.149 second, and NYHA class III or ambulatory class IV heart failure symptoms during optimal medical therapy

NYHA class I or class II heart failure symptoms and non-LBBB QRS pattern with QRS duration < 0.15 second

Comorbidity and/or frailty that will limit survival with good functional status to < 1 year