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2021

ESC 2021 Guidelines — Cardiac Pacing and Resynchronization Therapy

2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy

The 2021 guideline brought conduction system pacing into formal recommendations and reorganised the evaluation of bradycardia and conduction disease around whether symptoms can be attributed to the rhythm.

That attribution is the examinable core. Pacing is not indicated for asymptomatic bundle branch block, for bradycardia with a reversible cause, or for high-degree block that resolves after revascularisation — and each of these is a separate numbered statement. Reversible causes that come up repeatedly include drug accumulation, sleep apnoea and ischaemia.

The resynchronisation recommendations are threshold-driven and the QRS duration and morphology do real work; a device is not indicated below the cut-off without an independent pacing indication. Specific settings have their own recommendations — cardiac sarcoidosis, pacing after transcatheter aortic valve implantation, pacing after cardiac surgery — and so do procedural details such as confirming lead position in more than one projection.

What is in the bank

103 active questions. Class and level follow the recommendation each question is built from.

Class of recommendation

Class I
29
Class IIa
43
Class IIb
22
Class III
9

Level of evidence

Level A
10
Level B
33
Level C
60

Sample questions

Cardiac pacing and cardiac resynchronization therapy · 2021Class IIILevel B
A 73-year-old man has an electrocardiogram as part of a routine occupational health screen. It shows left bundle branch block with a QRS duration of 148 ms, which was not present on a tracing from four years ago. He reports no dizziness, no syncope, no palpitations and no breathlessness, plays tennis twice a week without limitation, and his examination and blood pressure are normal. The occupational physician asks whether he needs a pacemaker to pre-empt progression to complete heart block. What is recommended?
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