Recommendations for Permanent Pacing in Sinus Node Dysfunction


Class I

(1) Permanent pacemaker implantation is indicated for sinus node dysfunction with documented symptomatic bradycardia, including frequent sinus pauses that produce symptoms.


(2) Permanent pacemaker implantation is indicated for symptomatic chronotropic incompetence.


(3) Permanent pacemaker implantation is indicated for symptomatic sinus bradycardia that results from required drug therapy for medical conditions.



Class IIa

(1) Permanent pacemaker implantation is reasonable for SND with heart rate less than 40 bpm when a clear association between significant symptoms consistent with bradycardia and the actual presence of bradycardia has not been documented.


(2) Permanent pacemaker implantation is reasonable for syncope of unexplained origin when clinically significant abnormalities of sinus node function are discovered or provoked in electrophysiological studies.



Class IIb

(1) Permanent pacemaker implantation may be considered in minimally symptomatic patients with chronic heart rate less than 40 bpm while awake.


Class III

(1) Permanent pacemaker implantation is not indicated for SND in asymptomatic patients.


(2) Permanent pacemaker implantation is not indicated for SND in patients for whom the symptoms suggestive of bradycardia have been clearly documented to occur in the absence of bradycardia


(3) Permanent pacemaker implantation is not indicated for SND with  symptomatic bradycardia due to nonessential drug therapy.




JACC. 2008; 51; 2085-2105.



2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay

 

 

CLASS I:

1.  In patients who develop symptomatic sinus bradycardia as a consequence of

    guideline directed management and therapy for which there is no alternative

    treatment and continued treatment is clinically necessary, permanent

    pacing is recommended to increase heart rate and improve symptoms 

   (Kusumoto et al.  2018 ACC / AHA / HRS Bradycardia Clinical Practice Guidelines 

    Circulation. 2019; 140:e382–e482)


 

 

CLASS IIA:

For patients with tachy-brady syndrome and symptoms attributable to

bradycardia, permanent pacing is reasonable to increase heart rate and reduce symptoms

attributable to hypoperfusion.  (Kusumoto et al.  2018 ACC / AHA / HRS Bradycardia 

Clinical Practice Guidelines Circulation. 2019; 140:e382–e482)


 

In patients with symptomatic chronotropic incompetence, permanent pacing with

rate responsive programming is reasonable to increase exertional heart rates

and improve symptoms.  (Kusumoto et al.  2018 ACC / AHA / HRS Bradycardia 

Clinical Practice Guidelines Circulation. 2019; 140:e382–e482)




CLASS IIB:

In patients with symptoms that are likely attributable to SND, a trial of oral

theophylline may be considered to increase heart rate, improve symptoms, and

help determine the potential effects of permanent pacing (Kusumoto et al.  

2018 ACC / AHA / HRS Bradycardia Clinical Practice Guidelines Circulation. 

2019; 140:e382–e482)


Kusumoto et al.  2018 ACC / AHA / HRS Bradycardia Clinical Practice Guidelines (Circulation. 2019; 140:e382–e482)