Comments on the new ESC guidelines on pacemaker and cardiac resynchronization therapy [Kommentar zu den neuen ESC-Leitlinien zur Schrittmacher- und kardialen Resynchronisationstherapie]

The guidelines of the European Society of Cardiology (ESC) on cardiac pacing and cardiac resynchronization therapy (CRT) from 2007 have been updated and comprehensively edited to reflect new study results on the indications for device implantation and to facilitate the application in routine daily practice. In sick sinus syndrome, threshold values for the minimum duration of the pause and bradycardia heart rates have been omitted since they may have different implications depending on structural heart disease, vagal tone and physical fitness. Atrioventricular (AV) block is divided into intrinsic (organic) and extrinsic (functional, e. g. during high vagal tone) conduction disorders. While the indications for pacemaker implantation are simplified and broader than before for intrinsic AV blocks, they are stricter than before for extrinsic, vagally-induced pauses and bradycardia. Instead of implanting a pacemaker, an improved correlation of symptoms to bradycardia by prolonged monitoring is recommended and vagally-induced asymptomatic pauses (sinus arrest or AV block) are considered for pacemaker therapy only if they exceed 6 s. For patients in sinus rhythm (permanent or intermittent), systems involving the atrium are recommended. In AV block and reduced left ventricular function CRT should be considered. To establish the indications for CRT in heart failure, the most important parameter is the bundle branch block morphology and for non-left bundle branch block morphology a QRS > 150 ms was downgraded to class IIa and for a QRS of 120–150 ms to class IIb. The use of systems compatible with magnetic resonance imaging (MRI) and remote monitoring should generally be considered. The new guidelines provide valuable help, the indications on routine pacemaker therapy are simpler, well-founded and more easily related to patients. © 2015, Springer-Verlag Berlin Heidelberg.