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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThe new 2013 European Society of Cardiology (ESC) Guidelines on cardiac pacing and cardiac resynchronization therapy (CRT) were recently published in the \u003Cem\u003EEuropean Heart Journal\u003C\/em\u003E and \u003Cem\u003EEuropace\u003C\/em\u003E [Brignole M et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2013; \u003Cem\u003EEuropace\u003C\/em\u003E 2013]. Michele The structural goals of the new guidelines were to provide short and simple indications with a description of both benefits and potential complications related to each treatment. In addition, acknowledgement was made of any differing opinions by any of the contributors from the final recommendations.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology \u0026amp; Cardiovascular Medicine\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EThe new 2013 European Society of Cardiology (ESC) Guidelines on cardiac pacing and cardiac resynchronization therapy (CRT) were recently published in the \u003Cem\u003EEuropean Heart Journal\u003C\/em\u003E and \u003Cem\u003EEuropace\u003C\/em\u003E [Brignole M et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2013; \u003Cem\u003EEuropace\u003C\/em\u003E 2013]. Michele Brignole, MD, Ospedali del Tigullio, Tigullio Lavagna, Italy, introduced the structure of the manuscript, the contributors, and the concepts behind the level of evidence. The structural goals of the new guidelines were to provide short and simple indications with a description of both benefits and potential complications related to each treatment. In addition, acknowledgement was made of any differing opinions by any of the contributors from the final recommendations. The quality of evidence that was used to make a recommendation is also noted in the guidelines, including whether or not additional data is likely or not likely to change a recommendation.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003ERichard Sutton, MD, St. Mary\u0027s Hospital, London, United Kingdom, presented the new ESC recommendations for cardiac pacing for bradycardia. The ESC guidelines recommend pacing in patients with sinus node disease when the symptoms are clearly attributed or most likely due to bradycardia [Brignole M et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2013; \u003Cem\u003EEuropace\u003C\/em\u003E 2013]. However, if sinus node disease is asymptomatic or reversible, pacing is not indicated. Pacing is also recommended in patients with third- or second-degree type 2 atrioventricular (AV) block, and in patients with second-degree type 1 AV block with symptoms due or located at intra-His or infra-His levels.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EThe new guidelines state that pacing is indicated in carotid sinus syncope (CSS) if patients have dominant cardioinhibitory carotid sinus syndrome and recurrent unpredictable syncope, or tilt-induced cardioinhibitory syncope with recurrent and frequent unpredictable syncope, if they are aged \u0026gt;40 years. However, Prof. Sutton pointed out that CSS is a relatively benign condition, as it does not appear to reduce survival. Therefore, pacing may help relieve syncope burden, as pacing results in a 75% decrease in recurrence compared with the natural history of the condition. Syncopal recurrence occurs in \u223c20% of patients within 5 years.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EVictoria Delgado, MD, Leiden University Medical Center, Leiden, The Netherlands, discussed the guideline updates on CRT in patients in sinus rhythm. Patients with and without left bundle branch block, a QRS duration of 120 ms or more, a left ventricular ejection fraction (LVEF) of \u226435%, and who remain in NYHA Functional Class II, III, or ambulatory IV are candidates for CRT [Brignole M et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2013; \u003Cem\u003EEuropace\u003C\/em\u003E 2013]. Patients with a QRS duration of \u0026lt;120 ms are not recommended to receive CRT. A meta-analysis of the effect of QRS duration on outcomes following CRT demonstrated a combined risk ratio (RR) of 0.60 (95% CI, 0.53 to 0.67; p\u0026lt;0.001) in patients with a QRS duration of 150 ms or greater and an RR of 0.95 (95% CI, 0.82 to 1.10; p=0.49) in patients with a QRS duration of 120 to 149 ms [Sipahi I et al. \u003Cem\u003EAnn Intern Med\u003C\/em\u003E 2011].\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EInterestingly, there were differences of opinion among the contributors of the 2013 ESC Guidelines in regards to the recommendations for CRT in patients in sinus rhythm [Brignole M et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2013; \u003Cem\u003EEuropace\u003C\/em\u003E 2013]. Dissent was primarily due to the data on which the recommendations were based; some recommendations are based on subanalyses of randomized controlled trials and their interpretation may be problematic. Therefore, the ESC Guidelines acknowledge that additional data may change the recommendations in the future.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EPacing mode is mostly recommended to be biventricular (BiV), as a survival benefit and decreased hospitalization is associated with BiV pacing compared with LV pacing [Brignole M et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2013; \u003Cem\u003EEuropace\u003C\/em\u003E 2013]. However, Prof. Delgado pointed out that LV pacing lowers the cost and complexity of the procedure, while potentially increasing the lifespan of the device. Therefore, LV pacing may be considered in children and young adults.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EChristophe Leclercq, MD, PhD, Rennes University Hospital, Rennes, France, discussed CRT in patients with atrial fibrillation (AF). Prof. Leclercq highlighted that there is a lack of CRT randomized controlled trials that are dedicated to or include patients with AF, yet \u223c25% of patients that receive CRT have AF. Patients are candidates for CRT only if they have permanent or long-standing, persistent AF.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EProf. Leclercq presented data that demonstrated that AF patients that received BiV pacing \u0026gt;98.5% of the time experienced a greater survival rate, compared with AF patients that had BiV pacing \u0026lt;98.5% (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Hayes D et al. \u003Cem\u003EHeart Rhythm\u003C\/em\u003E 2011].\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/12\/6\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Effect of Biventricular Pacing in Patients With AF\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-442669589\u0022 data-figure-caption=\u0022Effect of Biventricular Pacing in Patients With AF\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/12\/6\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/12\/6\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/12\/6\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13623\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-10\u0022 class=\u0022first-child\u0022\u003EEffect of Biventricular Pacing in Patients With AF\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EAF=atrial fibrillation; BiV=biventricular.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced from Hayes DL et al. Cardiac resynchronization therapy and the relationship of percent biventricular pacing to symptoms and survival. \u003Cem\u003EHeart Rhythm\u003C\/em\u003E 2011;8(9):1469\u20131475. With permission from Elsevier.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-11\u0022\u003EAV node ablation appears to be important in patients with AF, with benefits to survival and remodeling [Gasparini M et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2006; Ganesan AN et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2012]. In addition, the 2013 ESC Guidelines recommend that patients with uncontrolled heart rate with AF that are candidates for AV ablation should also be considered for pacing [Brignole M et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2013; \u003Cem\u003EEuropace\u003C\/em\u003E 2013]. Prof. Leclercq noted that although the evidence is fairly weak for CRT in patients with persistent AF, the prevailing expert opinion is that CRT should be considered and AV ablation should be added in patients that have a BiV capture of \u0026lt;99%.\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003ECecilia Linde, MD, Karolinska University Hospital, Solna, Sweden, presented on CRT in patients with conventional pacemakers. The 2013 ESC Guidelines state that upgrading from a conventional pacemaker or implantable cardioverter-defibrillator (ICD) to CRT is recommended in patients with NYHA II-III HF or ambulatory NYHA IV, LVEF \u0026lt;35% despite optimal medical therapy and who have a high percentage of ventricular pacing; with the goal of decreasing the risk of worsening HF [Brignole M et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2013; \u003Cem\u003EEuropace\u003C\/em\u003E 2013]. In several small randomized crossover studies, patients with HF NYHA III to IV and LVEF of \u0026lt;40% that were upgraded to CRT experienced symptomatic improvements and decreased hospitalizations, as compared with right ventricular (RV) pacing. In a survey study, patients that had \u003Cem\u003Ede novo\u003C\/em\u003E and upgraded CRT experienced similar rates of survival (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [Bogale N et al. \u003Cem\u003EEur J Heart Fail\u003C\/em\u003E 2011].\u003C\/p\u003E\u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/12\/6\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Survival Rate Following de Novo Implantation or Upgrade to CRT\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-442669589\u0022 data-figure-caption=\u0022\u0026amp;lt;div xmlns=\u0026amp;quot;http:\/\/www.w3.org\/1999\/xhtml\u0026amp;quot;\u0026amp;gt;Survival Rate Following \u0026amp;lt;em\u0026amp;gt;de Novo\u0026amp;lt;\/em\u0026amp;gt; Implantation or Upgrade to CRT\u0026amp;lt;\/div\u0026amp;gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/12\/6\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/12\/6\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/12\/6\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13625\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n            \u003Cp id=\u0022p-13\u0022 class=\u0022first-child\u0022\u003ESurvival Rate Following \u003Cem\u003Ede Novo\u003C\/em\u003E Implantation or Upgrade to CRT\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003EReproduced from Bogale N et al. The European Cardiac Resynchronization Therapy Survey: comparison of outcomes between de novo cardiac resynchronization therapy implantations and upgrades. \u003Cem\u003EEur J Heart Fail\u003C\/em\u003E 2011;13(9):973\u2013983. With permission from Oxford University Press.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-14\u0022\u003EProf. Linde highlighted the recommendation that patients with bradycardia should be considered for \u003Cem\u003Ede novo\u003C\/em\u003E CRT because a high extent of right ventricular (RV) pacing has been shown to be associated with an increased risk for hospitalizations and deterioration of LV function in prior studies of patients paced due to sinus node disease or those receiving an ICD.\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003E\n         \u003Cem\u003EDe novo\u003C\/em\u003E CRT compared with RV pacing was studied in the BLOCK HF trial [Curtis AB et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2013] in patients in need of ventricular pacing because of high degree AV block with reduced LVEF defined as LVEF \u0026lt;50%. CRT (BiV pacing) resulted in a relative risk reduction of 23% of HF hospitalizations and death compared with RV pacing over a 2-year follow-up.\u003C\/p\u003E\u003Cp id=\u0022p-16\u0022\u003EThe 2013 ESC Guidelines include updates from the 2010 Guidelines. The document provides new and updated recommendations in a novel structure that aims to enhance the reader\u0027s ability to quickly and easily identify a topic of interest.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2013 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/13\/12\/6.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nznpo1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nznpo1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}