What management strategies should be considered for patients with symptomatic heart block, particularly in the context of pacing?

Management strategies for patients with symptomatic heart block, particularly regarding pacing, include:

• Consider permanent pacing for symptomatic second degree or third degree atrioventricular (AV) block to relieve symptoms and prevent complications.
• Before pacing, assess and optimize any reversible causes of heart block if possible.
• After pacing, reassess symptoms and the need for further interventions such as AV node ablation if symptoms persist, especially in the context of atrial fibrillation with high ventricular rates.
• In patients with permanent atrial fibrillation and symptoms or left ventricular dysfunction caused by high ventricular rates, consider a "pace and ablate" strategy, which involves pacing combined with AV node ablation to control ventricular rate and improve symptoms.
• Referral to cardiology is essential for patients with symptomatic heart block to evaluate the need for pacing and further specialist management.

These strategies aim to manage symptoms, prevent syncope, and improve cardiac function by ensuring adequate heart rate control through pacing interventions.

References: NICE CKS, NICE NG196