This document presents guidelines for cardiac pacing and cardiac resynchronization therapy (CRT) from the European Society of Cardiology (ESC). It was developed by an international Task Force and covers recommendations for using pacemakers to treat various arrhythmias and heart failure. The guidelines provide evidence-based recommendations for indications and modes of pacing in conditions like sinus node disease, atrioventricular block, and heart failure. It also reviews the clinical effects of CRT as supported by randomized controlled trials. The task force developed the first ESC guidelines on appropriate use of pacemaker devices in Europe.

1. Committee for Practice Guidelines (CPG) 1Committee for Practice Guidelines (CPG) 1Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 11
Guidelines for Cardiac Pacing and
Cardiac Resynchronisation Therapy
The Task Force for Cardiac Pacing and
Cardiac Resynchronisation Therapy of the
European Society of Cardiology
Developed in collaboration with the
European Heart Rhythm Association

2. Committee for Practice Guidelines (CPG) 2Committee for Practice Guidelines (CPG) 2Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 22
Authors/Task Force Members
Angelo Auricchio (Switzerland)
Jean-Jacques Blanc (France)
Jean-Claude Daubert (France)
Helmut Drexler (Germany)
Hugo Ector (Belgium)
Maurizio Gasparini (Italy)
Cecilia Linde (Sweden)
Francisco Bello Morgado (Portugal)
Ali Oto (Turkey)
Richard Sutton (UK)
Maria Trusz-Gluza (Poland)
Chairperson: Panos E. Vardas (Greece)

3. Committee for Practice Guidelines (CPG) 3Committee for Practice Guidelines (CPG) 3Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 33

4. Committee for Practice Guidelines (CPG) 4Committee for Practice Guidelines (CPG) 4Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 44
Introduction
• The guidelines for the appropriate use of pacemaker
devices presented in this document, a joint ESC and
EHRA initiative, aim to provide for the first time in
Europe an up to date specialists' view of the field.
• The guidelines cover two main areas: the first
includes permanent pacing in bradyarrhythmias,
syncope, and other specific conditions, while the
second refers to ventricular resynchronisation as an
adjunct therapy in patients with heart failure.

5. Committee for Practice Guidelines (CPG) 5Committee for Practice Guidelines (CPG) 5Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 55
Classes of Recommendations

6. Committee for Practice Guidelines (CPG) 6Committee for Practice Guidelines (CPG) 6Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 66
Levels of Evidence

7. Committee for Practice Guidelines (CPG) 7Committee for Practice Guidelines (CPG) 7Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 77
1. Pacing for Arrhythmias

8. Committee for Practice Guidelines (CPG) 8Committee for Practice Guidelines (CPG) 8Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 88
1.1. Sinus node disease
Recommendations for cardiac pacing in sinus node disease

9. Committee for Practice Guidelines (CPG) 9Committee for Practice Guidelines (CPG) 9Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 99
Pacemaker mode selection in sinus node disease

10. Committee for Practice Guidelines (CPG) 10Committee for Practice Guidelines (CPG) 10Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 1010
1.2. Atrioventricular and intraventricular
conduction disturbances
Recommendations for cardiac pacing in acquired AV block

11. Committee for Practice Guidelines (CPG) 11Committee for Practice Guidelines (CPG) 11Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 1111
1.2. Atrioventricular and intraventricular
conduction disturbances
Recommendations for cardiac pacing in chronic bi- and tri-fascicular block

12. Committee for Practice Guidelines (CPG) 12Committee for Practice Guidelines (CPG) 12Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 1212
Pacemaker mode selection in acquired atrioventricular
block, chronic bifascicular and trifascicular block

13. Committee for Practice Guidelines (CPG) 13Committee for Practice Guidelines (CPG) 13Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 1313
1.3. Recent myocardial infarction
Recommendations for permanent cardiac pacing in conduction
disturbances related to acute myocardial infarction

14. Committee for Practice Guidelines (CPG) 14Committee for Practice Guidelines (CPG) 14Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 1414
1.4. Reflex syncope
The main causes of reflex syncope

15. Committee for Practice Guidelines (CPG) 15Committee for Practice Guidelines (CPG) 15Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 1515
Recommendations for cardiac pacing
in carotid sinus syndrome

16. Committee for Practice Guidelines (CPG) 16Committee for Practice Guidelines (CPG) 16Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 1616
Recommendations for cardiac pacing
in vasovagal syncope

17. Committee for Practice Guidelines (CPG) 17Committee for Practice Guidelines (CPG) 17Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 1717
1.5. Paediatrics and congenital heart diseases
Recommendations for cardiac pacing in
paediatrics and congenital heart disease

18. Committee for Practice Guidelines (CPG) 18Committee for Practice Guidelines (CPG) 18Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 1818
1.5. Paediatrics and congenital heart diseases
Recommendations for cardiac pacing in
paediatrics and congenital heart disease

19. Committee for Practice Guidelines (CPG) 19Committee for Practice Guidelines (CPG) 19Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 1919
1.5. Paediatrics and congenital heart diseases
Recommendations for cardiac pacing in
paediatrics and congenital heart disease

20. Committee for Practice Guidelines (CPG) 20Committee for Practice Guidelines (CPG) 20Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 2020
1.6. Cardiac transplantation
Recommendations for cardiac pacing
after cardiac transplantation

21. Committee for Practice Guidelines (CPG) 21Committee for Practice Guidelines (CPG) 21Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 2121
2. Pacing for Specific Conditions

22. Committee for Practice Guidelines (CPG) 22Committee for Practice Guidelines (CPG) 22Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 2222
2.1. Hypertrophic cardiomyopathy
Recommendations for cardiac pacing
in hypertrophic cardiomyopathy

23. Committee for Practice Guidelines (CPG) 23Committee for Practice Guidelines (CPG) 23Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 2323
3. Cardiac Resynchronisation Therapy (CRT)
in Patients with Heart Failure
• State-of-the-art management of congestive heart failure (CHF), besides
alleviating symptoms, preventing major morbidity, and lowering mortality,
increasingly strives to prevent disease progression, in particularly the
transition between asymptomatic LV dysfunction and overt CHF.
• The clinical effects of long-term CRT were firstly evaluated in non-
controlled studies, in which a sustained benefit conferred by biventricular
pacing was measured. Randomized multi-centre trials with crossover or
parallel treatment assignments were subsequently conducted to ascertain
the clinical value of CRT in patients with advanced CHF and in sinus
rhythm, with or without indications for an implantable cardioverter-
defibrillator (ICD). Meta-analyses were also published.
• The usual study enrolment criteria were: 1) CHF in New York Heart
Association (NYHA) functional Class III or IV despite optimal
pharmacological treatment; 2) LV ejection fraction (EF) < 35%, LV end-
diastolic diameter > 55 mm, and QRS duration ≥ 120 or 150 ms.
Evidence-based clinical effects of CRT

24. Committee for Practice Guidelines (CPG) 24Committee for Practice Guidelines (CPG) 24Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 2424
• Pacing for heart failure can be applied either by biventricular pacing or,
in selected cases, by left ventricular pacing alone. The following
recommendations consider cardiac pacing for heart failure delivered
through biventricular pacing, since this mode is supported by the
greatest body of evidence. This, however, does not preclude other
pacing modes, such as LV pacing, to correct ventricular dyssynchrony.
• Ventricular conduction delay continues to be defined according to QRS
duration (QRS ≥ 120 ms). It is recognised that ventricular conduction
delay may not result in mechanical dyssynchrony. Dyssynchrony is
defined as an uncoordinated regional contraction-relaxation pattern.
Although from the theoretical point of view it may be more appropriate to
target mechanical dyssynchrony, rather than electrical conduction delay,
no large controlled study has prospectively assessed the value of
mechanical dyssynchrony in heart failure patients undergoing pacing for
heart failure.
3. Cardiac Resynchronisation Therapy (CRT)
in Patients with Heart Failure
Recommendations

25. Committee for Practice Guidelines (CPG) 25Committee for Practice Guidelines (CPG) 25Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 2525
3. Cardiac Resynchronisation Therapy (CRT)
in Patients with Heart Failure

26. Committee for Practice Guidelines (CPG) 26Committee for Practice Guidelines (CPG) 26Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 2626
3. Cardiac Resynchronisation Therapy (CRT)
in Patients with Heart Failure

27. Committee for Practice Guidelines (CPG) 27Committee for Practice Guidelines (CPG) 27Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 2727
3. Cardiac Resynchronisation Therapy (CRT)
in Patients with Heart Failure