Assessing compliance with ESC 2021 guidelines for cardiac Investigations prior to permanent pacemaker implantation

Aim

To evaluate compliance with ESC 2021 guideline recommendations for cardiac and systemic investigations prior to permanent pacemaker (PPM) implantation.

Methods

A retrospective audit of 149 consecutive adults undergoing de novo PPM implantation over a 12-month period (1 January 2024 to 31 December 2024). Data were extracted from electronic health records. Compliance with ESC-recommended universal investigations (ECG, echocardiography, renal profile) and conditional investigations (NT-proBNP, advanced imaging, rare-disease screening) was assessed.

Results

The audit included patients with a mean age of 78 ± 9 years; 56% were male, and 71% underwent inpatient implantation. All patients had a pre-implant ECG. Echocardiography was performed in 86.6% of cases, but only 62.4% were within the ESC-recommended one-year pre/post-implant window. Documentation of key parameters such as, chamber dimensions, wall thickness, and diastolic function, was frequently incomplete.

Few patients with an ejection fraction <50% or NT-proBNP >2000 ng/L were referred for specialist heart failure assessment. Use of advanced imaging was low: cardiac MRI in 5.4%, PET-CT in 3.4%, and bone scintigraphy for amyloidosis in 1.3%. Biochemical screening for rare diseases was inconsistently undertaken, and two infiltrative cardiomyopathies were identified. One-year mortality was 6%, with one cardiovascular death.

Conclusion

Universal core investigations were widely undertaken, with all patients receiving ECG and most undergoing echocardiography. However, true compliance with ESC 2021 recommendations was limited because many echocardiograms were performed outside the guideline-specified timeframe and key parameters were frequently undocumented. Compliance with conditional investigations (including advanced imaging, biomarker testing, and referral pathways) was suboptimal, especially in patients with reduced EF or markedly elevated NT-proBNP. These findings suggest potential under-recognition of infiltrative cardiomyopathy. Standardised pre-implant evaluation pathways may improve diagnostic accuracy and guideline adherence.For image description, please refer to the figure legend and surrounding text.For image description, please refer to the figure legend and surrounding text.