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Circulation. 2002;106:2145-2161
doi: 10.1161/01.CIR.0000035996.46455.09
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(Circulation. 2002;106:2145.)
© 2002 American Heart Association, Inc.

ACC/AHA Practice Guidelines

ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices: Summary Article

A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee to Update the 1998 Pacemaker Guidelines)

, Committee Members: Gabriel Gregoratos, MD, FACC, FAHA, Chair; Jonathan Abrams, MD, FACC, FAHA; Andrew E. Epstein, MD, FACC, FAHA; Roger A. Freedman, MD, FACC; David L. Hayes, MD, FACC, FAHA; Mark A. Hlatky, MD, FACC, FAHA; Richard E. Kerber, MD, FACC, FAHA; Gerald V. Naccarelli, MD, FACC, FAHA; Mark H. Schoenfeld, MD, FACC, FAHA; Michael J. Silka, MD, FACC; Stephen L. Winters, MD, FACC

, Task Force Members: Raymond J. Gibbons, MD, FACC, FAHA, Chair; Elliott M. Antman, MD, FACC, FAHA, Vice-Chair; Joseph S. Alpert, MD, FACC, FAHA; Gabriel Gregoratos, MD, FACC, FAHA; Loren F. Hiratzka, MD, FACC, FAHA; David P. Faxon, MD, FACC, FAHA; Alice K. Jacobs, MD, FACC, FAHA; Valentin Fuster, MD, PhD, FACC, FAHA; Sidney C. Smith, Jr, MD, FACC, FAHA


Key Words: ACC/AHA Scientific Statements • pacemakers • arrhythmia • defibrillation • syncope

The current update of the ACC/AHA/NASPE Guidelines for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices includes several significant changes in the recommendations and in the supporting narrative portion. In this summary, we list the updated recommendations along with the respective 1998 recommendations, each one accompanied by a brief comment outlining the rationale for the changes, additions, or deletions. All new or revised recommendations are listed in the second column and appear in boldface type. References that support either the 1998 recommendations that have not changed or the new or revised recommendations are noted in parentheses at the end of each recommendation. The reader is referred to the full-text version of the guidelines posted on the American College of Cardiology (ACC), American Heart Association (AHA), and North American Society for Pacing and Electrophysiology (NASPE) World Wide Web sites for a more detailed exposition of the rationale for these changes. In addition to the recommendation changes listed here, this update includes an expanded section on the selection of pacemakers and implantable cardioverter-defibrillators (ICDs) that reflects the technical advances that have taken place since 1998. A brief expanded summary of pacemaker follow-up procedures is also new to these guidelines. For both of these expanded sections, the reader is referred to the online full-text version.

In preparing this update, the committee was guided by the following principles:

  1. Changes in recommendations and levels of evidence were made either because of new randomized trials or because of the accumulation of new clinical evidence and the development of clinical consensus.
  2. The committee is cognizant of the healthcare, logistic, and financial implications of recent trials and factored in these considerations in arriving at the class level of certain recommendations.
  3. Minor wording changes were made to render some recommendations more precise.
  4. The committee wishes to re-emphasize that the recommendations in the guideline apply to most patients but may require modification by existing situations that only the primary treating physician can evaluate properly.
  5. All of the listed recommendations for implantation of a device presume the absence of inciting causes that may be eliminated without detriment to the patient (eg, nonessential drug therapy).
  6. The committee endeavored to maintain consistency of recommendations in this and other previously published guidelines. In the section on atrioventricular (AV) block associated with acute myocardial infarction (AMI), the recommendations follow closely those in the ACC/AHA Guideline for the Management of Patients With Acute Myocardial Infarction.1 However, given the rapid evolution of pacemaker/ICD science, it has not always been possible to maintain consistency with other guidelines. An example of such a discrepancy can be found in Section I-H, in which the recommendation for biventricular pacing in selected patients with heart failure has been listed under Class IIa, whereas in the ACC/AHA Guideline for the Evaluation and Management of Chronic Heart Failure in the Adult,2 biventricular pacing is cited as an investigational procedure.

The ACC/AHA classifications I, II, and III are used to summarize indications as follows:

Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective.

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.

IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.

IIb: Usefulness/efficacy is less well established by evidence/opinion.

Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful.

The weight of the evidence was ranked highest (A) if the data were derived from multiple randomized clinical trials that involved large numbers of patients and intermediate (B) if the data were derived from a limited number of randomized trials that involved small numbers of patients or from careful analyses of nonrandomized studies or observational registries. A lower rank (C) was given when expert consensus was the primary basis for the recommendation. Down


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*    Footnotes
 
This document was approved by the American College of Cardiology Foundation Board of Trustees in September 2002, the American Heart Association Science Advisory and Coordinating Committee in August 2002, and the North American Society for Pacing and Electrophysiology in August 2002.

The ACC/AHA Task Force on Practice Guidelines makes every effort to avoid any actual or potential conflicts of interest that might arise as a result of an outside relationship or personal interest of a member of the writing panel. Specifically, all members of the writing panel are asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest. These statements are reviewed by the parent task force, reported orally to all members of the writing panel at the first meeting, and updated as changes occur. The conflict of interest information for the writing committee members is posted on the ACC, AHA, and NASPE Web sites with the full-length version of the update.

When citing this document, the ACC, the AHA, and NASPE would appreciate the following citation format: Gregoratos G, Abrams J, Epstein AE, Freedman RA, Hayes DL, Hlatky MA, Kerber RE, Naccarelli GV, Schoenfeld MH, Silka MJ, Winters SL. ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices: Summary Article: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee to Update the 1998 Pacemaker Guidelines). Circulation. 2002;106:2145–2161.

Copies: This document is available on the World Wide Web sites of the ACC (www.acc.org), the AHA (www.americanheart.org), and NASPE (www.naspe.org). A single copy of the complete guidelines is available by calling 800-253-4636 (US only) or writing the American College of Cardiology Foundation, Resource Center, 9111 Old Georgetown Rd, Bethesda, MD 20814-1699 (ask for No. 71-0237). To obtain a copy of the Summary Article, ask for reprint No. 71-0236. To purchase additional reprints (specify version and reprint number): up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 410-528-4426, fax 410-528-4264, or e-mail kbradle@lww.com.


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