Dr James Rosengarten reports highlights from the European Heart Rhythm Association (EHRA) Europace 2013 meeting held recently in Athens, Greece.
The 2013 ESC Guidelines on Cardiac Pacing and Cardiac Resynchronisation Therapy1 developed in collaboration with the EHRA, were launched at the meeting and also published simultaneously in the European Heart Journal and EP Europace. They have been redesigned to offer a more accessible format with greater emphasis on a practical ‘how to’ approach, which is targetted at generalists, including general practitioners and geriatricians, as well as cardiologists and electrophysiologists.
“By taking this user friendly approach we hope to get our messages out to the wider medical community, which ultimately should allow more patients to benefit from the latest evidence-based medicine,” explained Professor Michele Brignole (Ospedali del Tigullio, Italy), Chairperson of the Guidelines on Cardiac Pacing and Cardiac Resynchronisation Therapy Task Force.
The guidelines explore:
- indications for pacing in patients who have cardiac arrhythmias
- indications for cardiac resynchronisation therapy (CRT) in heart failure
- indications for pacing in specific conditions, such as acute MI, pacing after cardiac surgery, transcatheter aortic valve implantation (TAVI) and heart transplantation, and pacing in children and individuals with congenital heart diseases
- complications of pacing and CRT implantation
- management considerations, such as re-implantation after device explantation for infection, MRI in patients with implanted cardiac devices, emergency (transvenous) temporary pacing and remote management of arrhythmias and devices.
The Guidelines take into account whether the patient has a persistent or intermittent problem, and whether it has been documented with electrocardiographic evidence (ECG documented) or not (ECG-undocumented).
The new ESC Guidelines have also created a new classification system for bradyarrhythmias according to mechanisms rather than aetiology.
Until now, guidelines have classified bradyarrhythmias according to aetiology, for example whether the problem has been caused by sinus node dysfunction, MI, or bundle branch block.
“One of the big innovations of these guidelines is the development of a logical decision tree displaying the different pacing modes according to different clinical situations. In effect these guidelines take the clinician by the hand and lead them through a series of three or four questions,” explained Professor Perry Elliott (The Heart Hospital, London), a member of the Guidelines Committee.
Pacemaker or ICD?
With over 90 major studies on pacing and resynchronisation published since the last guidelines, the Task Force went to considerable efforts to integrate the latest research. In areas where evidence is open to more than one interpretation, the guidelines provide information to help clinicians make a decision. For example, in patients with heart failure and poorly controlled symptoms, where choices have to be made between CRT pacemakers and CRT defibrillators, trials have had little to add to the decision-making process. “Clinicians have to consider factors such as expected life expectancy and comorbidities when choosing between pacemaker and defibrillator therapy,” said Professor Elliott.
Wessex Electrophysiology Fellow and BJCA Deanery Representative
- Brignole M, Auricchio A, Baron-Esquivias G et al. for the Task Force on cardiac pacing and resynschronisation therapy of the European Society of Cardiology. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronisation therapy Eur Heart J 2013; http://dx.doi.org/10.1093/eurheartj/eht150 and Europace 2013; http://dx/doi.org/10.1093/europace/eut206