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Pacemaker Therapy: Indications and Recommendations

Howard Lanney, MD, MS
Yijia Hu, MD
Sydney C. Karnovsky, MD

American Family Physician. 2026;113(6):551-558.

Author disclosure: No relevant financial relationships.

This clinical content conforms to AAFP criteria for CME.

Pacemakers are implantable cardiac devices used in the treatment of bradycardia and heart failure. They monitor electrical signals in the heart and deliver electrical stimuli to cause contraction in the targeted heart chamber. Permanent pacemaker therapy is recommended in patients with symptomatic bradycardia or asymptomatic infranodal atrioventricular block to improve symptoms and quality of life. Biventricular pacemakers can also be used in cardiac resynchronization therapy, which corrects dyssynchrony between the ventricles. In patients who have symptomatic heart failure with reduced ejection fraction, left bundle branch block, and prolonged QRS duration, cardiac resynchronization therapy improves outcomes, including mortality. Medical procedures such as electrocautery or magnetic resonance imaging may interfere with a patient's pacemaker; family physicians should coordinate with cardiologists to ensure appropriate care for patients in whom these procedures are indicated.

Pacemakers are implantable cardiac devices that monitor electrical signals in the heart and deliver electrical stimuli to cause contraction in the targeted heart chamber. They are indicated to improve symptoms of bradycardia, prevent high-degree atrioventricular block (AVB) from degenerating into complete heart block, and promote ventricular synchrony and improve survival in certain patients. Table 11,2 and Table 22 provide specific indications for pacemakers from recent guidelines. At least 200,000 pacemakers are implanted in the United States each year.3 As the population ages, the prevalence and complexity of patients with pacemakers will increase.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
In patients with symptoms that are attributable to sinus node dysfunction, permanent pacing improves symptoms.1,2,8 B Consensus guidelines based on observational data and a randomized controlled trial
Permanent pacing is not recommended in asymptomatic patients with sinus bradycardia, sinus pauses, first-degree atrioventricular block, or second-degree Mobitz type I block.1,2 C Limited data and consensus guidelines
In patients with second-degree Mobitz type II block or third-degree atrioventricular block without a reversible cause, permanent pacing is recommended regardless of symptoms.1,2 C Consensus guidelines based on older observational studies
In patients with symptomatic heart failure despite maximally tolerated medical therapy with left ventricular ejection fraction ≤ 35%, QRS dura tion ≥ 150 msec, and left bundle branch block, cardiac resynchronization therapy is indicated to reduce mortality.2,14–16 A Randomized controlled trials and consensus guidelines
Primary care physicians should coordinate with cardiologists to manage pacemakers in patients at the end of life and during procedures that involve electrocautery or magnetic resonance imaging.2,23–25 C Expert opinion

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

TABLE 1. Guideline-Based Indications for Permanent Pacemaker Therapy

Indication Recommendation from ACC/AHA/HRS and ESC guidelines*
AVB  
Symptomatic AVB caused by treatment for another condition without an alternative Recommended1
Third-degree AVB, second-degree Mobitz type II block, or infranodal 2: 1 AVB, regardless of symptoms Recommended1,2
Symptoms clearly attributable to first-degree AVB and PR interval > 0.3 seconds Should be considered1,2
Symptoms clearly attributed to second-degree Mobitz type I block Should be considered1,2
Bundle branch block  
Alternating bundle branch block (left bundle branch block then right bundle branch block on successive electrocardiograms, or right bundle branch block with left anterior fascicular block then right bundle branch block with left posterior fascicular block on successive electrocardiograms) Recommended1,2
Unexplained syncope, bifascicular block, and abnormal electrophysiology study results Recommended1,2
Unexplained syncope and bifascicular block without electrophysiology study May be considered2
Sinus node dysfunction  
Symptomatic bradycardia caused by treatment for another condition without an alternative Recommended1,2
Symptoms clearly attributable to sinus node dysfunction Recommended1,2
Asymptomatic sinus pause > 6 seconds and history of syncope May be considered2
Symptoms that are likely, but not conclusively, due to bradycardia May be considered2

ACC = American College of Cardiology; AHA = American Heart Association; AVB = atrioventricular block; ESC = European Society of Cardiology; HRS = Heart Rhythm Society.

*—Joint guidelines from the ACC, AHA, and HRS, as well as guidelines from the ESC.

Information from references 1 and 2.

HOWARD LANNEY, MD, MS, is an assistant professor in the Department of Family Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts.

YIJIA HU, MD, is an assistant professor in the Department of Family Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston.

SYDNEY C. KARNOVSKY, MD, is a primary care and sports medicine physician at Mass General Brigham and a clinical instructor of medicine at Harvard Medical School, Boston, Massachusetts.

Address correspondence to Howard Lanney, MD, MS, at howard.lanney@bmc.org.

Author disclosure: No relevant financial relationships.

  1. 1.Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2019;140(8):e382-e482.
  2. 2.Glikson M, Nielsen JC, Kronborg MB, et al.; ESC Scientific Document Group. 2021 ESC guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J. 2021;42(35):3427-3520.
  3. 3.Greenspon AJ, Patel JD, Lau E, et al. Trends in permanent pacemaker implantation in the United States from 1993 to 2009: increasing complexity of patients and procedures. J Am Coll Cardiol. 2012;60(16):1540-1545.
  4. 4.Chung MK, Daubert JP. Pacemakers and implantable cardioverterdefibrillators. In: Libby P, Bonow RO, Mann DL, et al., eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Elsevier;2022:1321–1348.
  5. 5.Honarbakhsh S, Hunter L, Chow A, et al. Bradyarrhythmias and pacemakers. BMJ. 2018;360:k642.
  6. 6.Bernstein AD, Daubert JC, Fletcher RD, et al.; North American Society of Pacing and Electrophysiology/British Pacing and Electrophysiology Group. The revised NASPE/BPEG generic code for antibradycardia, adaptive-rate, and multisite pacing. Pacing Clin Electrophysiol. 2002;25(2):260-264.
  7. 7.Mulpuru SK, Madhavan M, McLeod CJ, et al. Cardiac pacemakers: function, troubleshooting, and management. Part 1 of a 2-part series. J Am Coll Cardiol. 2017;69(2):189-210.
  8. 8.Alboni P, Menozzi C, Brignole M, et al. Effects of permanent pacemaker and oral theophylline in sick sinus syndrome the THEOPACE study: a randomized controlled trial. Circulation. 1997;96(1):260-266.
  9. 9.Andersen HR, Nielsen JC, Thomsen PE, et al. Long-term follow-up of patients from a randomised trial of atrial versus ventricular pacing for sick-sinus syndrome. Lancet. 1997;350(9086):1210-1216.
  10. 10.Lamas GA, Lee KL, Sweeney MO, et al.; Mode Selection Trial in Sinus-Node Dysfunction. Ventricular pacing or dual-chamber pacing for sinus-node dysfunction. N Engl J Med. 2002;346(24):1854-1862.
  11. 11.Dretzke J, Toff WD, Lip GYH, et al. Dual chamber versus single chamber ventricular pacemakers for sick sinus syndrome and atrioventricular block. Cochrane Database Syst Rev. 2004(2):CD003710.
  12. 12.Kirk JA, Kass DA. Cellular and molecular aspects of dyssynchrony and resynchronization. Card Electrophysiol Clin. 2015;7(4):585-597.
  13. 13.Lindenfeld J, Zile MR. Devices for monitoring and managing heart failure. Libby P, Bonow RO, Mann DL, et al., eds. In: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Elsevier;2022:1107–1118.
  14. 14.Cleland JGF, Daubert JC, Erdmann E, et al.; Cardiac Resynchronization-Heart Failure (CARE-HF) Study Investigators. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 2005;352(15):1539-1549.
  15. 15.Bristow MR, Saxon LA, Boehmer J, et al.; Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) Investigators. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med. 2004;350(21):2140-2150.
  16. 16.Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2022;79(17):e263-e421.
  17. 17.Mararenko A, Udongwo N, Pannu V, et al. Intracardiac leadless versus transvenous permanent pacemaker implantation: impact on clinical outcomes and healthcare utilization. J Cardiol. 2023;82(5):378-387.
  18. 18.Cantillon DJ, Exner DV, Badie N, et al. Complications and health care costs associated with transvenous cardiac pacemakers in a nationwide assessment. JACC Clin Electrophysiol. 2017;3(11):1296-1305.
  19. 19.Birnie DH, Healey JS, Wells GA, et al.; BRUISE CONTROL Investigators. Pacemaker or defibrillator surgery without interruption of anticoagulation. N Engl J Med. 2013;368(22):2084-2093.
  20. 20.Kusumoto FM, Schoenfeld MH, Wilkoff BL, et al. 2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. Heart Rhythm. 2017;14(12):e503-e551.
  21. 21.Reynolds D, Duray GZ, Omar R, et al.; Micra Transcatheter Pacing Study Group. A leadless intracardiac transcatheter pacing system. N Engl J Med. 2016;374(6):533-541.
  22. 22.Al-Khatib SM. Cardiac implantable electronic devices. N Engl J Med. 2024;390(5):442-454.
  23. 23.Indik JH, Gimbel JR, Abe H, et al. 2017 HRS expert consensus statement on magnetic resonance imaging and radiation exposure in patients with cardiovascular implantable electronic devices. Heart Rhythm. 2017;14(7):e97-e153.
  24. 24.Wan EY, Rogers AJ, Lavelle M, et al.; American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Surgery and Anesthesia; and Council on Peripheral Vascular Disease. Periprocedural management and multidisciplinary care pathways for patients with cardiac implantable electronic devices: a scientific statement from the American Heart Association. Circulation. 2024;150(8):e183-e196.
  25. 25.Lampert R, Hayes DL, Annas GJ, ; American College of C, American Geriatrics S, et al.; American Academy of Hospice and Palliative Medicine; American Heart Association; European Heart Rhythm Association; Hospice and Palliative Nurses Association. HRS expert consensus statement on the management of cardiovascular implantable electronic devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy. Heart Rhythm. 2010;7(7):1008-1026.
  26. 26.Denay KL, Johansen M. Common questions about pacemakers. Am Fam Physician. 2014;89(4):279-282.
  27. 27.Gregoratos G. Indications and recommendations for pacemaker therapy. Am Fam Physician. 2005;71(8):1563-1570.
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