What is the most important clinical feature that establishes the need for cardiac pacing?

The most important clinical feature consists of symptoms clearly associated with bradycardia secondary to AV block. Reversible causes such as digoxin or beta blockers should be sought, and, when possible, the offending agents should be discontinued. This is not always possible, especially if a medication is necessary for the control of tachyrhythmia. Symptomatic bradycardia is the cardinal feature in the placement of a permanent pacemaker in acquired AV block in adults. The many clinical manifestations of symptomatic bradycardia include lightheadedness, dizziness, near syncope, frank syncope, manifestations of cerebral ischemia, dyspnea on exertion, decreased exercise tolerance, and even congestive heart failure.

In what clinical settings is placement of a pacemaker indicated in acquired AV block?

Pacing is indicated for third-degree (complete) block that is either permanent or paroxysmal when it is associated with symptoms that are clearly related to (1) bradycardia, (2) congestive heart failure, (3) treatment to suppress other rhythms or to control medical conditions (digitalis for congestive heart failure with agents that suppress automaticity of pacemaker tissue, (4) an escape rhythm 40 beats/min or asystole for 3.0 seconds (may be symptom free), (5) mental cloudiness that clearly resolves with temporary pacing, (5) ablation of the AV node, and (6) myotonic dystrophy.

Pacing is indicated in second-degree block, regardless of the site, when symptoms are clearly related to heart block.

Pacing is also indicated in the setting of atrial fibrillation or flutter when it is associated with complete third-degree block or advanced second-degree block resulting in bradycardia and any of the above conditions (1-6).

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