Cardiac Pacing and Resynchronization Clinical Practice Guidelines (ESC/EHRA, 2021)

European Society of Cardiology (ESC), European Heart Rhythm Association (EHRA)

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

October 01, 2021

Updated guidelines on cardiac pacing and cardiac resynchronization therapy (CRT) were published in August 2021 by the European Society of Cardiology (ESC) and European Heart Rhythm Association (EHRA) in Europace.[1,2] Emphasis has been placed on patient-centered care, shared decision making, and appropriate workup/testing prior to pacemaker implantation.

New recommendations include those for pacing after syncope, pacing following transcatheter aortic valve implantation (TAVI), CRT for heart failure (HF) and for prevention of pacing-induced cardiomyopathy, and pacing in various infiltrative and inflammatory diseases of the heart, as well as in different cardiomyopathies.[1,2] New sections include those on pacing the His bundle (HBP) and the left bundle branch (LBB), as well as on evaluation of suspected or documented bradycardia or conduction system disease.

Select Key Messages

Cardiac pacing

Cardiac pacing is indicated in patients with:

  • Sinus node dysfunction (SND), including those with bradycardia–tachycardia type of SND, when symptoms are clearly attributed to bradyarrhythmia

  • Sinus rhythm (SR) and permanent or paroxysmal third- or second-degree type 2 or high-degree atrioventricular block (AVB), irrespective of symptoms

Single-lead ventricular pacing is indicated in the setting of permanent atrial fibrillation (AF) and permanent or paroxysmal AVB.

In the setting of syncope and unexplained falls, determine the diagnosis using available diagnostic methods before considering pacemaker therapy.

Cardiac resynchronization therapy

CRT is recommended in patients with symptomatic HF and left ventricular (LV) ejection fraction (EF) ≤35% despite optimal medical therapy (OMT) who are in SR and have LBB block (LBBB) QRS morphology, when QRS duration is ≥150 ms. Consider CRT in these patients when QRS duration is 130–149 ms.

In the setting of non-LBBB QRS morphology, less convincing evidence exists for the benefit of CRT, especially with normal PR and QRS duration <150 ms. CRT should not be used in patients with HF and QRS duration <130 ms unless ventricular pacing is needed.

Consider CRT in those with permanent AF, symptomatic HF, LVEF ≤35%, and QRS ≥130 ms who remain in New York Heart Association (NYHA) class III or ambulatory IV despite OMT.

Consider AV junction (AVJ) ablation for those with AF and CRT when at least 90-95% effective biventricular pacing is not achievable.

For patients with high-degree AVB and an indication for cardiac pacing who have HF with reduced EF (HFrEF) (LVEF <40%), the ESC/EHRA recommend CRT rather than right ventricular (RV) pacing.

His bundle pacing

HBP may:

  • Result in normal or near-normal ventricular activation; it is an attractive alternative to RV pacing

  • Be considered for select patients with AVB and LVEF >40%, who are anticipated to have >20% ventricular pacing

  • Correct ventricular conduction in a subset of patients with LBBB; thus, it may be used in lieu of biventricular pacing for HBP-based CRT in select patients

In patients offered HBP, individual consideration should be given for implanting an RV lead used as “backup” for pacing. In patients treated with HBP, tailor the device programming to the specific requirements of HBP.

Consider implantation of a leadless pacemaker when no upper extremity venous access exists, when the risk of device pocket infection is particularly heightened, and in patients on hemodialysis.

TAVI, other surgeries, and perioperative considerations

Undergoing TAVI raises the risk of developing AVB. Base decisions regarding post-TAVI cardiac pacing on preexisting and new conduction disturbances. Consider ambulatory electrocardiographic (ECG) monitoring for 7-30 days or electrophysiologic studies (EPS) in post-TAVI patients who have new LBBB or progression of a preexisting conduction anomaly, but who do not yet have any indication for a pacemaker.

In patients undergoing surgery for endocarditis or tricuspid valve surgery who have or develop AVB under surgery, consider placing epicardial pacing leads during surgery.

To reduce the risk of complications:

  • Administer preoperative antibiotics before cardiovascular implantable electronic device (CIED) procedures

  • Chlorhexidine–alcohol should be preferred for skin antisepsis

  • Attempt cephalic or axillary vein access as first choice

  • Avoid heparin bridging in CIED procedures to minimize the risk of hematoma and pocket infection

  • Consider use of an antibiotic-eluting envelope in CIED reintervention procedures to lower the infection risk

Radiation therapy can be offered to patients with a pacemaker or CRT—provided individualized treatment planning and risk stratification is done beforehand and the device is interrogated as recommended around the period of radiation therapy.

For more information, please go to Transvenous Cardiac Pacing, Transcutaneous Cardiac Pacing, and Cardiac Resynchronization Therapy.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.