Mechanisms rather than etiology have been used to create a new classification system for bradyarrhythmias in the 2013 ESC Guidelines on Cardiac Pacing and Cardiac Resynchronization Therapy developed in collaboration with the European Heart Rhythm Association (EHRA).
The guidelines, presented at the EHRA EUROPACE meeting 23-26 June in Athens, Greece, and published simultaneously in the European Heart Journal
and Europace, have been redesigned to offer a more accessible format for users. Greater emphasis than ever before has been placed on a practical 'how to' approach targeted at generalists, including GPs and geriatricians, as well as expert cardiologists and electro physiologists.
"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 Michele Brignole (Ospedali del Tigullio, Italy), Chairperson of the Guidelines on Cardiac Pacing and Cardiac Resynchronization Therapy Task Force.
The 2013 guidelines, revised for the first time since 2007, were developed with input from 70 clinicians, including an expert Task Force of 18 cardiologists specializing in cardiac pacing and resynchronization, a further 26 experts in the field who reviewed the document, with the entire process overseen by the ESC Committee for Practice Guidelines (CPG).
The first part of the guidelines explores indications for pacing in patients who have cardiac arrhythmias. The second part looks at indications for cardiac resynchronization therapy in heart failure. The third part includes indications for pacing in specific conditions, such as acute MI, pacing after cardiac surgery, TAVI and heart transplantation, and pacing in children and individuals with congenital heart diseases. Finally, the guidelines explore management considerations such as re implantation after device explanation for infection, magnetic resonance imaging in patients with implanted cardiac devices, emergency (transvenous) temporary pacing and remote management of arrhythmias and devices.
The new ESC Guidelines take into account whether the patient has a persistent problem, or whether it is intermittent, and whether it has been documented with electrocardiographic evidence (ECG documented) or not (ECG-undocumented). Until now, guidelines have classified bradyarrhythmias according to aetiology, for example whether the problem has been caused by sinus node dysfunction, myocardial infarction (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, UK) a member of the Guidelines committee.
With over 90 major studies on pacing and resynchronization 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,ŧ said Prof Elliott.
These guidelines are the first ESC Guidelines ever to incorporate a new section called 'Clinical perspectives'. "This section gives advice on how to apply guidelines in real life clinical situations, taking into account things like what to do when patients have co morbidities or are taking concomitant drugs," explained Prof Brignole.
The abridged pocket version of the guidelines, due to be launched at the main ESC Congress in Amsterdam, 31st August to 4 September 2013, should further simplify the guidelines and make them accessible to an even wider audience.