The following are key points to remember from the European Society of Cardiology (ESC) and the European Heart Rhythm Association (EHRA) about the 2021 Guidelines on Cardiac Pacing and Cardiac Resynchronization Therapy (CRT):

1. A careful history and physical examination are essential for the evaluation of patients with suspected or documented bradycardia. In patients with suspected or documented symptomatic bradycardia, the use of cardiac imaging is recommended to evaluate the presence of structural heart disease, to determine left ventricular (LV) systolic function, and to diagnose potential reversible causes of conduction disturbances. Exercise testing is recommended in patients who experience symptoms suspicious of bradycardia during or immediately after exertion.
2. Screening for sleep apnea syndrome is recommended in patients with symptoms of sleep apnea syndrome and in the presence of severe bradycardia or advanced atrioventricular (AV) block during sleep. In patients with infrequent unexplained syncope, in whom a comprehensive evaluation did not demonstrate a cause, long-term ambulatory monitoring with an implantable loop recorder is recommended. Multimodality imaging (cardiac magnetic resonance, computed tomography, or positron emission tomography) should be considered in search of the underlying myocardial disease, particularly in patients with conduction system disease who are <60 years. Genetic testing should be considered in patients with early-onset (age <50 years) of progressive cardiac conduction disease.
3. In patients with syncope and bifascicular block, electrophysiologic study (EPS) should be considered when syncope remains unexplained after noninvasive evaluation. In such patients, a pacemaker is indicated in the presence of either a baseline His-ventricular interval of ≥70 ms, second- or third-degree intra- or infra-Hisian block during incremental atrial pacing, or an abnormal response to pharmacological challenge. Pacing is indicated in patients with alternating bundle branch block (BBB) with or without symptoms.
4. Dual-chamber cardiac pacing is indicated to reduce recurrent syncope in patients aged >40 years, with severe, unpredictable, recurrent syncope who have: 1) spontaneous documented symptomatic asystolic pause(s) >3 seconds or asymptomatic pause(s) >6 seconds due to sinus arrest or AV block; or 2) cardioinhibitory carotid sinus syndrome; or 3) asystolic syncope during tilt testing.
5. CRT is recommended for symptomatic patients with heart failure (HF) in sinus rhythm with LV ejection fraction (LVEF) ≤35%, QRS duration ≥150 ms, and left bundle branch block (LBBB) QRS morphology. CRT should be considered for symptomatic patients with HF in sinus rhythm with LVEF ≤35%, QRS duration 130-149 ms, and LBBB QRS morphology. CRT should be considered for patients with HF in sinus rhythm with LVEF ≤35%, QRS duration ≥150 ms, and non-LBBB QRS morphology. CRT should be considered for patients with HF and LVEF ≤35% in NYHA class III or IV if they are in atrial fibrillation (AF) and have intrinsic QRS ≥130 ms, provided a strategy to ensure biventricular capture is in place. AV junction ablation should be added in the case of incomplete biventricular pacing (<90-95%) due to conducted AF.
6. In patients with sinus node dysfunction and a DDD pacemaker, minimization of unnecessary ventricular pacing through programming is recommended.
7. Conduction system pacing (which includes His bundle and left bundle branch area pacing) is very likely to play a growing role in the future, pending randomized trials of safety and efficacy.
8. Leadless pacemakers should be considered as an alternative to transvenous pacemakers when no upper extremity venous access exists or when risk of device pocket infection is particularly high, such as previous infection and patients on hemodialysis. The prevalence of leadless device infections is low as the principal sources of infection. There are no randomized controlled data available to compare clinical outcomes between leadless pacing and single-chamber transvenous pacing.
9. Right bundle branch block (RBBB) is the most consistent and powerful predictor of the need for pacing after transcatheter aortic valve implantation (TAVI). Early permanent pacing should be considered in patients with pre-existing RBBB who develop any further conduction disturbance during or after TAVI. Permanent pacemaker implantation appears warranted in patients with intraprocedural AV block that persists for 24-48 hours after TAVI or appears later. Ambulatory electrocardiographic (ECG) monitoring or EPS should be considered for patients with new LBBB with QRS >150 ms or PR >240 ms with no further prolongation during >48 hours after TAVI. Ambulatory ECG monitoring or EPS may be considered for patients with a pre-existing conduction abnormality who develop prolongation of QRS or PR >20 ms.
10. Not all patients with congenital heart block require pacing, especially if they are asymptomatic. Prophylactic pacing is indicated in asymptomatic patients with any of the following risk factors: 1) mean daytime heart rate <50 bpm, 2) pauses >3 times the cycle length of the ventricular escape rhythm, 3) a broad QRS escape rhythm, 4) prolonged QT interval, or 5) complex ventricular ectopy. Clinical symptoms, such as syncope, pre-syncope, HF, or chronotropic incompetence, are indications for pacemaker implantation.
11. A clinically significant pocket hematoma increases the risk for subsequent device infection almost eightfold. In patients with low and intermediate thrombotic risk after PCI (>1 month after PCI, or >6 months after acute coronary syndrome at index PCI), the recommendation is to continue aspirin AND discontinue P2Y12 inhibitors. It is recommended that vitamin K anticoagulant is continued periprocedurally. Either stopping or continuing nonvitamin K antagonist oral anticoagulants might be reasonable at the time of device implantation.
12. Infection rates are higher with device replacement or upgrade procedures, as well as CRT or implantable cardioverter-defibrillator implants compared with simple pacemaker implantation. Infections also occur more frequently with use of temporary pacing or other procedures before implantation (odds ratio [OR] 2.5 and 5.8, respectively), early reinterventions (OR 15), and lack of antibiotic prophylaxis (OR 2.5).
13. In patients considered for pacemaker or CRT, the decision should be based on the best available evidence with consideration of individual risk–benefits, the patient’s preferences, and goals of care, and it is recommended to follow an integrated care approach and use the principles of patient-centered care and shared decision making in the consultation.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Imaging, Sleep Apnea

Keywords: ESC21, ESC Congress, Anticoagulants, Anti-Arrhythmia Agents, Arrhythmias, Cardiac, Atrial Fibrillation, Atrioventricular Block, Bradycardia, Bundle-Branch Block, Cardiac Resynchronization Therapy, Defibrillators, Implantable, Diagnostic Imaging, Electrocardiography, Exercise Test, Genetic Testing, Heart Conduction System, Heart Failure, Hematoma, Monitoring, Ambulatory, Pacemaker, Artificial, Percutaneous Coronary Intervention, Physical Examination, Renal Dialysis, Risk Factors, Secondary Prevention, Sleep Apnea Syndromes, Syncope, Transcatheter Aortic Valve Replacement, Ventricular Premature Complexes, Vitamin K

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