Atrioventricular Block Guidelines

Updated: Jul 13, 2022
  • Author: Chirag M Sandesara, MD, FACC, FHRS; Chief Editor: Jose M Dizon, MD  more...
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Guidelines Summary

The following are recommendations from the 2012 American College of Cardiology Foundation/American Heart Association/Heart Rhythm Society (ACCF/AHA/HRS) focused update of their 2008 guidelines for device-based therapy of cardiac rhythm abnormalities. [2]

Class I indications for implantation of a permanent pacemaker in atrioventricular (AV) block

  • Advanced second-degree AV block (two or more consecutive P waves are blocked)
  • Symptomatic Mobitz I second-degree block
  • Symptomatic Mobitz II second-degree block
  • Mobitz II second-degree block with wide QRS or chronic bifascicular block, with or without symptoms
  • Exercise-induced second- or third-degree AV block in the absence of ischemia
  • Second- or third-degree AV block in asymptomatic awake patients in sinus rhythm, resulting in periods of asystole longer than 3.0 sec or ventricular rates less than 40 beats per minute
  • Second -or third-degree AV block in asymptomatic awake patients in atrial fibrillation, resulting in pauses of at least 5 seconds
  • AV node ablation
  • Advanced second- or third-degree AV block with or without symptoms associated with neuromuscular diseases (eg, myotonic dystrophy, Kearns-Sayer syndrome, Erb dystrophy [limb-girdle muscular dystrophy]), and peroneal muscular atrophy
  • Recurrent syncope due to carotid massage, causing ventricular pauses of longer than 3 seconds
  • AV block caused by a medication that is an essential drug therapy for another medical condition

In addition, permanent pacemaker implantation is recommended after acute myocardial infarction for the following:

  • Symptomatic and persistent second- and third-degree AV block
  • Persistent second-degree AV block in the His-Purkinje system
  • Alternating bundle branch block
  • Third-degree AV block at or below the His bundle
  • Transient infranodal AV block with bundle branch block

Class II indications for implantation of a permanent pacemaker in AV block

  • Alternating bundle branch block
  • Bifascicular or trifascicular block with syncope
  • First-degree AV block in associated neuromuscular diseases
  • First-degree AV block causing bradycardia and hypotension due to very long PR intervals resulting in AV dissociation
  • Asymptomatic Mobitz II AV second-degree AV block with a narrow QRS complex
  • Second-degree AV block found during electrophysiology study to be infra-AV nodal

Class III (pacing not indicated) conditions in patients with AV block

  • Asymptomatic Mobitz I second-degree AV block
  • Reversible AV block (due to electrolyte abnormalities, Lyme disease, sleep apnea, enhanced vagal tone, following surgery, medications)