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September 14, 1984, Vol 252, No. 10 >
ARTICLE | September 14, 1984

Indications for Pacing in the Treatment of Bradyarrhythmias: Title and subTitle BreakReport of an Independent Study Group FREE

Brendan Phibbs, MD; Howard S. Friedman, MD; Thomas B. Graboys, MD; Bernard Lown, MD; Henry J. L. Marriott, MD; William P. Nelson, MD; Thomas Preston, MD
[+] Author Affiliations

Reprint requests to Kino Community Hospital, 2800 E Ajo Way, Tucson, AZ 85713 (Dr Phibbs).


JAMA. 1984;252(10):1307-1311. doi:10.1001/jama.1984.03350100037026
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Article
References

Indications for permanent pacing in the bradyarrhythmias are summarized. In the absence of symptoms, pacing is justified only when Mobitz type II block or complete atrioventricular (AV) block is localized in the bundlebranch system. All other abnormalities of impulse generation or conduction (incomplete AV block of any type, atrial fibrillation with slow ventricular response, or sinus node dysfunction) must be shown to be stable and intrinsic and to cause CNS symptoms or hemodynamic compromise to justify pacing. Isolated intra-Hisian abnormality without failure of AV conduction is benign. Measurement of HV interval does not contribute significant information. Correlation of carotid sinus sensitivity with carotid sinus syncope is poor (5%). Bradyarrhythmia produced by minimal effective doses of an essential drug is a rare indication for pacing and requires special documentation. Inadequate indications, sources of error, and misconceptions are discussed. Generally, it is important to exclude drug effect, transient clinical states, and correctable systemic disease as causes of the abnormality before making a conclusion about pacing.

(JAMA 1984;252:1307-1311)

REFERENCES

1 +
Chokshi AB, Friedman HS, Malach M, et al:  Impact of peer review and reduction of permanent pacemaker implantations . JAMA 1981;; 286:754-757.
2 +
Schamroth L: The Disorders of Cardiac Rhythm , ed 2. Oxford, England, Blackwell Scientific Publications, 1980;, p 189.
3 +
Griffith SP:  Congenital complete heart block . Circulation 1971;;43:615-617.
4 +
Katz L, Pick A: Clinical Electrocardiography: The Arrhythmias . Philadelphia, Lea & Febiger, 1956;, p 555.
5 +
Narula 0, Scherlag B:  Atrioventricular block, localization and classification by His bundle recording . Am J Med 1971;;50:146-164.
6 +
Wenckebach KF:  Beitrage zur Kenntnis der menschlichen Herztatigkeit . Arch Anat Physiol 1906;;1:297-332.
7 +
Langendorf F, Pick A:  Atrioventricular block type II (Mobitz): Its nature and clinical significance . Circulation 1968;;38:819-821.
8 +
Massumi RA, Ali N:  Determination of the site of impaired conduction in atrioventricular block . J Electrocardiol 1970;;3:193.
9 +
Dhingra R, Wyndham C, Amat-y-leon F, et al:  Incidence and site of atrioventricular block in patients with chronic bifascicular block . Circulation 1979;;59:238-245.
10 +
Rosen KM, Dhingra R, Loeb H, et al:  Chronic heart block in adults: Clinical and electrophysiological observations . Arch Intern Med 1973;;131:663-672.
11 +
Hunt D, Studley J, Vohra J:  Wenckebach block in the distal conduction system . Aust NZ J Med 1974;;4:392-395.
12 +
Amat-y-leon F, Dhingra R, Denes P, et al:  The clinical spectrum of chronic His bundle block . Chest 1976;;6:747-754.
13 +
Gupta PK, Lichstein E, Chadda KD:  Electrophysiologic features of Mobitz type II block occurring within the His bundle . Br Heart J 1972;;34:1232-1237.
14 +
Kastor JA:  Atrioventricular block . N Engl J Med 1975;;292:572-574.
15 +
Strasberg B, Amat-y-leon F, Dhingra R, et al:  Natural history of chronic second-degree atrioventricular nodal block . Circulation 1981;; 63:1043-1049.
16 +
Graybiel A, McFarland RA:  Analysis of electrocardiograms obtained from 1,000 young healthy aviators . Am Heart J 1944;;27:524-549.
17 +
Hiss RG, Lamb LE, Allen MF:  Electrocardiographic findings in 67,375 asymptomatic subjects: X. Normal values . Am J Cardiol 1960;; 6:200-231.
18 +
Rubenstein J, Schulman C, DeSanctis R, et al:  Clinical spectrum of the sick sinus syndrome . Circulation 1972;;46:5-13.
19 +
Shaw D, Holman R, Gowers J:  Survival in sinoatrial disorder (sick sinus syndrome) . Br Med J 1980;;1:139-141.
20 +
Alpert M, Flaker G:  Arrhythmias associated with sinus node dysfunction . JAMA 1983;; 250:2160-2166.
21 +
Evans TR, Callohill EA, Krikler DM:  Clinical value of tests of sinoatrial function . Pace 1978;;1:2-7.
22 +
Narula O:  Sick sinus syndrome: Key references . Circulation 1979;;60:1422-1424.
23 +
Altshuler H, Fisher J, Furman S:  Significance of isolated HV interval prolongation in symptomatic patients without documented heart block . Am Heart J 1979;;97:19-26.
24 +
McAnulty J, Murphy E, Rahimtoola S:  A prospective evaluation of intra Hisian conduction delay . Circulation 1979;;59:1035-1039.
25 +
Josephson M, Seides S: Clinical Cardiac Elect rophysiology: Techniques and Interpretations . Philadelphia, Lea & Febiger, 1979;, p 88.
26 +
McAnulty J, Rahimtoola S, Murphy E, et al:  Natural history of 'high risk' bundle branch block: Final report of a prospective study . N Engl J Med 1982;;307:137-143.
27 +
Dhingra R, Wyndham C, Bauernfeind R, et al:  Significance of a chronic bifascicular block without apparent organic heart disease . Circulation 1979;;60:33-39.
28 +
Scheinman M, Peters R, Sauvé MJ, et al:  Value of the HQ interval in patients with bundle branch block and the role of prophylactic permanent pacing . Am J Cardiol 1982;;50:1316-1322.
29 +
Surawicz B:  Prognosis of patients with chronic bifascicular block . Circulation 1979;; 60:40-42.
30 +
Leatham A:  Carotid sinus syncope . Br Heart J 1982;;47:409-410.
31 +
Franke H:  Uber das hyperactive Karotissinus Syndrome . Acta Neurovegetiva 1963;; 27:187-204.
32 +
Thomas J:  Hyperactive carotid sinus reflex and carotid sinus syndrome . Mayo Clin Proc 1969;;44:127-139.
33 +
Smiddy J, Lewis HD, Dunn M:  The effect of carotid massage in older men . J Gerontol 1972;;27:209-211.
34 +
Ritter W, Atkins J, Blomquist G, et al:  Permanent pacing in patients with transient trifascicular block during acute myocardial infarction . Am J Cardiol 1976;;38:205-208.
35 +
Dhingra R, Wyndham C:  Significance of block distal to the His bundle induced by atrial pacing in patients with chronic bifascicular block . Circulation 1979;;60:1455-1463.

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1 +
Chokshi AB, Friedman HS, Malach M, et al:  Impact of peer review and reduction of permanent pacemaker implantations . JAMA 1981;; 286:754-757.
2 +
Schamroth L: The Disorders of Cardiac Rhythm , ed 2. Oxford, England, Blackwell Scientific Publications, 1980;, p 189.
3 +
Griffith SP:  Congenital complete heart block . Circulation 1971;;43:615-617.
4 +
Katz L, Pick A: Clinical Electrocardiography: The Arrhythmias . Philadelphia, Lea & Febiger, 1956;, p 555.
5 +
Narula 0, Scherlag B:  Atrioventricular block, localization and classification by His bundle recording . Am J Med 1971;;50:146-164.
6 +
Wenckebach KF:  Beitrage zur Kenntnis der menschlichen Herztatigkeit . Arch Anat Physiol 1906;;1:297-332.
7 +
Langendorf F, Pick A:  Atrioventricular block type II (Mobitz): Its nature and clinical significance . Circulation 1968;;38:819-821.
8 +
Massumi RA, Ali N:  Determination of the site of impaired conduction in atrioventricular block . J Electrocardiol 1970;;3:193.
9 +
Dhingra R, Wyndham C, Amat-y-leon F, et al:  Incidence and site of atrioventricular block in patients with chronic bifascicular block . Circulation 1979;;59:238-245.
10 +
Rosen KM, Dhingra R, Loeb H, et al:  Chronic heart block in adults: Clinical and electrophysiological observations . Arch Intern Med 1973;;131:663-672.
11 +
Hunt D, Studley J, Vohra J:  Wenckebach block in the distal conduction system . Aust NZ J Med 1974;;4:392-395.
12 +
Amat-y-leon F, Dhingra R, Denes P, et al:  The clinical spectrum of chronic His bundle block . Chest 1976;;6:747-754.
13 +
Gupta PK, Lichstein E, Chadda KD:  Electrophysiologic features of Mobitz type II block occurring within the His bundle . Br Heart J 1972;;34:1232-1237.
14 +
Kastor JA:  Atrioventricular block . N Engl J Med 1975;;292:572-574.
15 +
Strasberg B, Amat-y-leon F, Dhingra R, et al:  Natural history of chronic second-degree atrioventricular nodal block . Circulation 1981;; 63:1043-1049.
16 +
Graybiel A, McFarland RA:  Analysis of electrocardiograms obtained from 1,000 young healthy aviators . Am Heart J 1944;;27:524-549.
17 +
Hiss RG, Lamb LE, Allen MF:  Electrocardiographic findings in 67,375 asymptomatic subjects: X. Normal values . Am J Cardiol 1960;; 6:200-231.
18 +
Rubenstein J, Schulman C, DeSanctis R, et al:  Clinical spectrum of the sick sinus syndrome . Circulation 1972;;46:5-13.
19 +
Shaw D, Holman R, Gowers J:  Survival in sinoatrial disorder (sick sinus syndrome) . Br Med J 1980;;1:139-141.
20 +
Alpert M, Flaker G:  Arrhythmias associated with sinus node dysfunction . JAMA 1983;; 250:2160-2166.
21 +
Evans TR, Callohill EA, Krikler DM:  Clinical value of tests of sinoatrial function . Pace 1978;;1:2-7.
22 +
Narula O:  Sick sinus syndrome: Key references . Circulation 1979;;60:1422-1424.
23 +
Altshuler H, Fisher J, Furman S:  Significance of isolated HV interval prolongation in symptomatic patients without documented heart block . Am Heart J 1979;;97:19-26.
24 +
McAnulty J, Murphy E, Rahimtoola S:  A prospective evaluation of intra Hisian conduction delay . Circulation 1979;;59:1035-1039.
25 +
Josephson M, Seides S: Clinical Cardiac Elect rophysiology: Techniques and Interpretations . Philadelphia, Lea & Febiger, 1979;, p 88.
26 +
McAnulty J, Rahimtoola S, Murphy E, et al:  Natural history of 'high risk' bundle branch block: Final report of a prospective study . N Engl J Med 1982;;307:137-143.
27 +
Dhingra R, Wyndham C, Bauernfeind R, et al:  Significance of a chronic bifascicular block without apparent organic heart disease . Circulation 1979;;60:33-39.
28 +
Scheinman M, Peters R, Sauvé MJ, et al:  Value of the HQ interval in patients with bundle branch block and the role of prophylactic permanent pacing . Am J Cardiol 1982;;50:1316-1322.
29 +
Surawicz B:  Prognosis of patients with chronic bifascicular block . Circulation 1979;; 60:40-42.
30 +
Leatham A:  Carotid sinus syncope . Br Heart J 1982;;47:409-410.
31 +
Franke H:  Uber das hyperactive Karotissinus Syndrome . Acta Neurovegetiva 1963;; 27:187-204.
32 +
Thomas J:  Hyperactive carotid sinus reflex and carotid sinus syndrome . Mayo Clin Proc 1969;;44:127-139.
33 +
Smiddy J, Lewis HD, Dunn M:  The effect of carotid massage in older men . J Gerontol 1972;;27:209-211.
34 +
Ritter W, Atkins J, Blomquist G, et al:  Permanent pacing in patients with transient trifascicular block during acute myocardial infarction . Am J Cardiol 1976;;38:205-208.
35 +
Dhingra R, Wyndham C:  Significance of block distal to the His bundle induced by atrial pacing in patients with chronic bifascicular block . Circulation 1979;;60:1455-1463.

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