Management of bradycardia

Last updated: November 23, 2022

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Bradycardia is generally defined as a heart rate of < 60/min. All patients require urgent evaluation with ECG and monitoring. Patients with unstable bradycardia require immediate stabilization, initially with IV atropine, followed by transcutaneous pacing and/or IV chronotropic medications (e.g., dopamine, epinephrine), and transvenous pacing for refractory bradycardia. Treatment should also address reversible underlying causes of bradycardia, e.g., hypoxemia, acute coronary syndrome, electrolyte disturbances, and medication-induced bradycardia. Stable patients may not require immediate intervention, but often require monitoring and investigations to determine the underlying etiology and risk of progression to unstable bradycardia or sudden cardiac death. Definitive management depends on the underlying cause of bradycardia and can include permanent pacemaker implantation for patients with nonreversible bradyarrhythmias.

See also “Overview of cardiac arrhythmias,” “Sinus node dysfunction,” “Atrioventricular block,” and “Cardiac implantable electronic devices.”

Approach [1][2]

Patients with unstable bradycardia need immediate stabilization with IV atropine, temporary cardiac pacing, and/or IV chronotropic medication, e.g., dopamine or epinephrine. [1]

Patients asymptomatic stable bradycardia or only mildly symptomatic stable bradycardia typically do not require acute intervention. [2]

Initial management of bradycardia

Do not delay acute stabilization of unstable bradycardia to obtain a 12-lead ECG for rhythm identification.

Overview of bradyarrhythmias

Clinical features of unstable bradycardia [1]

Adult unstable bradycardia algorithm [1][2]

Start initial management of bradycardia and immediate hemodynamic support simultaneously with the following treatment:

Concurrently treat reversible causes of bradycardia, e.g., hypoxia, hyperkalemia, acute coronary syndrome, beta blocker toxicity, CCB toxicity, cardiac glycoside toxicity.

Special situations [2]

Management

Disposition

  • Inpatient cardiology consult for all patients
  • Urgent cardiology consult if transvenous pacing is required
  • ICU or CCU admission

Provide initial management of bradycardia concurrently for all patients.

If signs of unstable bradycardia develop at any time, follow the adult unstable bradycardia algorithm.

Diagnostics [2]

Management

High-risk AV block is an indication for permanent pacemaker insertion.

Disposition [2]

Consult cardiology as disposition varies depending on underlying rhythm and etiology, symptom severity, and patient factors.

Transcutaneous pacing

  • Consider procedural sedation and analgesia for conscious patients. . [2]
  • Place the leads in the anteroposterior position.
  • Set output to a level that is likely to result in capture.
    • Unconscious patient: Start at 160–180 mA and decrease output if possible.
    • Conscious patient: Start at a low output (e.g., 10 mA) and gradually increase until capture is seen.
  • Set pacing rate to 60–80/min.
  • Set a backup rate at a low level to avoid unnecessary pacing (e.g., 30/min).
  • Verify ventricular capture by checking the patient's pulse manually or with pulse oximetry.

Transvenous pacing [4]

Acute management of reversible causes [2][3]

Medication-induced bradycardia [2]

Identify medications that may cause bradycardia (e.g., beta blockers, CCBs, digoxin, antiarrhythmics).

Stable bradycardia

Management depends on the indication and individual patient risk. Consult the prescribing clinician if available.

  • Noncritical medication: Consider temporary hold or permanent discontinuation.
  • Critical medication: Consider dosage reduction or alternative agents under specialist guidance.

Unstable bradycardia

Consider the following antidotes in addition to the adult unstable bradycardia algorithm:

Etiologies by underlying mechanism

Cause [2][5][6]

Increased vagal tone

Ischemia
Inflammatory/infiltrative
Infections
Metabolic/endocrine
Congenital
Degeneration of the conducting system
Iatrogenic
Medication
Other
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  2. 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. J Am Coll Cardiol. 2019; 74 (7): p.e51-e156. doi: 10.1016/j.jacc.2018.10.044 . | Open in Read by QxMD
  3. Neumar RW, Otto CW, Link MS, et al. Part 8: Adult Advanced Cardiovascular Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010; 122 (18_suppl_3): p.S729-S767. doi: 10.1161/circulationaha.110.970988 . | Open in Read by QxMD
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  8. Le T, Bhushan V, Bagga HS. First Aid for the USMLE Step 2 CK. McGraw-Hill Medical ; 2009
  9. Sauer WH. Normal Sinus Rhythm and Sinus Arrhythmia. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/normal-sinus-rhythm-and-sinus-arrhythmia.Last updated: November 15, 2016. Accessed: February 22, 2017.
  10. Homoud MK. Sinoatrial Nodal Pause, Arrest, and Exit Block. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/sinoatrial-nodal-pause-arrest-and-exit-block.Last updated: January 22, 2018. Accessed: April 13, 2018.
  11. Brubaker PH, Kitzman DW. Chronotropic Incompetence: Causes, Consequences, and Management. Circulation. 2011; 123 (9): p.1010-1020. doi: 10.1161/circulationaha.110.940577 . | Open in Read by QxMD
  12. Sinz E et al.. ACLS for Experienced Providers. American Heart Association ; 2013
  13. 2018 Guidelines Made Simple: Bradycardia and Cardiac Conduction Dela. https://www.acc.org/guidelines/hubs/bradycardia-and-cardiac-conduction-delay. . Accessed: January 14, 2020.
  14. Scherbak D, Hicks GJ. Left Bundle Branch Block (LBBB). StatPearls. 2019 .
  15. Soos, McComb. Sinus Arrhythmia. StatPearls. 2019 .
  16. Issa ZF, Miller JM, Zipes DP. Clinical Arrhythmology and Electrophysiology. Elsevier Health Sciences ; 2012

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