The Heart Rhythm Society has released its list of specific treatments and procedures related to heart rhythm disorders that are not always necessary. The Heart Rhythm Society developed the list as part of Choosing Wisely, an initiative of the American Board of Internal Medicine Foundation launched in 2012 aimed at curbing the use of certain tests and procedures that are not supported by clinical research.
According to a press release, the Heart Rhythm Society’s recommendations were developed by its Quality Improvement Subcommittee after months of careful consideration and review, using the most current evidence about management and treatment options. The final topics were selected by a vote of Subcommittee members and formally approved by the Heart Rhythm Society’s Board of Trustees. While the Heart Rhythm Society recommendations are based on clinical guidelines and evidence, the main goal is to foster healthy discussion and effective shared decision making around choices in heart rhythm care.
The five recommendations are as follows:
- Don’t implant pacemakers for asymptomatic sinus bradycardia in the absence of other indications for pacing.
While pacemaker implantation is clearly indicated in patients with symptomatic sinus node dysfunction, there is no clear evidence that pacemaker implantation benefits asymptomatic patients with sinus bradycardia who have no other reasons for pacing nor need for cardiac resynchronisation. Although pacemaker implantation is a relatively low-risk surgical procedure, like any operation, there is both risk and cost. Furthermore, persistent inappropriate right ventricular pacing may have harmful effects on heart function. Current professional society clinical guidelines recommend against (Class III, contraindicated) pacemaker implantation in these patients where the risks outweigh the benefits.
- Don’t implant an implantable cardioverter-defibrillator for the primary prevention of sudden cardiac death in patients with New York Heart Association Functional Class IV who are not candidates for either cardiac transplantation, a left ventricular assist device as destination therapy or cardiac resynchronisation therapy.
Because patients with severe (New York Heart Association functional class IV) congestive heart failure who are not eligible for advanced therapies such as ventricular assist devices, cardiac resynchronisation or cardiac transplantation have extremely high mortality, they were not included in the primary prevention trials of implantable cardioverter-defibrillator therapy. As such, current clinical professional society guidelines recommend against (Class III, contraindicated) implantation of an implantable cardioverter-defibrillator in such patients.
- Don’t implant an implantable cardioverter-defibrillator for the primary prevention of sudden cardiac death in patients unlikely to survive at least one year due to non-cardiac comorbidity.
Because the explicit goal of primary prevention of sudden death with an implantable cardioverter-defibrillator is the prevention of death due to life-threatening ventricular arrhythmias in patients with an otherwise reasonable expectation of survival, current clinical professional society guidelines recommend against (Class III,contraindicated) implantation of an implantable cardioverter-defibrillator when there is no reasonable expectation of survival from a non-cardiac illness for at least one year.
- Don’t ablate the atrioventricular node in patients with atrial fibrillation when both symptoms and heart rate are acceptably controlled by well-tolerated medical therapy.
Atrioventricular node ablation and pacemaker implantation may provide benefit in some patients when rate and related symptoms cannot be controlled by medication therapy,(Class IIa, indicated) or when there is concern for possible tachycardia-induced cardiomyopathy (Class IIb, may be considered). However, according to current professional society clinical guidelines, the risks of atrioventricular node ablation outweigh the benefits among patients with no symptoms and who have appropriate rate control with well-tolerated medical therapy.
- Don’t use Vaughan-Williams Class Ic antiarrhythmic drugs as a first-line agent for the maintenance of sinus rhythm in patients with ischemic heart disease who have experienced prior myocardial infarction.
Class Ic antiarrhythmic agents (i.e., flecainide and encainide,) have been demonstrated to increase mortality in patients treated with these agents after myocardial infarction, and as a result, current clinical professional society guidelines recommend against (Class III, contraindicated) the use of these agents (and propafenone, because it is also a Class Ic agent) in patients with known coronary artery disease with left ventricular dysfunction or concern for possible ischemic myocardium at risk.
“As leaders in the treatment of cardiac arrhythmias, the Heart Rhythm Society has a responsibility to make sure that our patients are receiving the best treatment options available,” said Hugh Calkins, president of the Heart Rhythm Society. “The Heart Rhythm Society Choosing Wisely list will help electrophysiologists identify treatments and procedures that may not be required and instead focus on high-quality care that will save our patients time and money.”