• Clinical science
  • Clinician

Management of bradycardia


Bradycardia is generally defined as a heart rate of < 60/min. The most important step in the acute management of bradycardia is determining if the patient is unstable, in which case atropine should be administered immediately. If IV access is not available and the patient is unstable, transcutaneous pacing should be initiated. The management of symptomatic, stable bradycardia is similar but should be tailored to the suspected cause of the bradycardia. Asymptomatic, stable bradycardia typically does not require treatment. Definitive management depends on the underlying cause of the bradycardia.

See also overview of cardiac arrhythmias, sick sinus syndrome, and atrioventricular block.


1. ABCDE survey [1]

  • No pulse: Start CPR (see ACLS).
  • Pulse present: Continue stepwise approach through ABCDE survey and proceed to the next step.
  • Identify and treat hypoxemia: supplemental oxygen to goal SpO2 > 94% [1]
  • Obtain a 12-lead ECG (only if immediately available)
  • Monitoring and supportive care
    • Continuous cardiac monitoring
    • Continuous pulse oximetry
    • Crash cart at the bedside
    • Frequent blood pressure assessment
    • IV access

2. Determine if the patient is stable or unstable [1]

Obtaining an ECG to identify the rhythm should not delay the acute management of unstable patients.

3. Determine if the patient is symptomatic or asymptomatic

4. Subsequent management

  • Perform a focused history and examination.
  • Identify and treat the underlying cause (see causes of bradycardia).
  • Consult cardiology and consider indications for permanent pacemaker (e.g., third-degree AV block).

Overview of bradycardia based on ECG findings

QRS complex width
Rhythm Narrow complex Wide complex

Unstable bradycardia with pulse

Signs of unstable bradycardia

Initial management [1]

Transcutaneous pacing

  • Consider procedural sedation.
  • 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.

Subsequent management

  • Continuous cardiac monitoring
  • Urgent cardiology consult
  • Prepare for transvenous pacemaker.
  • Identify and treat the underlying cause (see causes of bradycardia).
  • Consider permanent pacemaker insertion.
  • Admit to ICU or CCU.

Symptomatic, stable bradycardia

Most patients can be observed and will not require intervention; only patients with high-grade AV block or severe symptoms should be treated.

Initial management [2]

Special considerations [2]

Avoid atropine in patients with myocardial infarction or a recent heart transplant.

Subsequent management

  • Cardiology consult
  • Identify and treat the underlying cause (see causes of bradycardia).
  • Consider TTE and further imaging.
  • Consider admission to ICU or CCU.

Asymptomatic, stable bradycardia

Consider pacing therapy even in asymptomatic patients with second-degree AV block, Mobitz II, or third-degree AV block.

Causes of bradycardia

Cause [4][2][5]

Increased vagal tone

Degeneration of the conducting system
  • 1. 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): pp. S729–S767. doi: 10.1161/circulationaha.110.970988.
  • 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): pp. e51–e156. doi: 10.1016/j.jacc.2018.10.044.
  • 3. Burri H, Dayal N. Acute management of bradycardia in the emergency setting. Cardiovascular Medicine. 2018; 21(04): pp. 98–104. doi: 10.4414/cvm.2018.00554.
  • 4. Dietel M, Suttorp N, Zeitz M, et al. Harrisons Innere Medizin (2 Bände). ABW Wissenschaftsverlagsgesellschaft (2005); 2005.
  • 5. Dakkak W, Doukky R. Sick Sinus Syndrome. StatPearls. 2019. pmid: 29261930.
  • American Heart Association. American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - Part 7.3: Management of symptomatic bradycardia and tachycardia 2005. Circulation. 2005; 112(24, suppl): pp. IV–67–IV–77. doi: 10.1161/circulationaha.105.166558.
  • Yu VL, Stout JE, Galindo NS. Epidemiology and pathogenesis of Legionella infection. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-legionella-infection?source=machineLearning&search=legionellosis&selectedTitle=3%7E100&anchor=H9§ionRank=3#H9. Last updated April 7, 2016. Accessed August 15, 2016.
  • Le T, Bhushan V, Bagga HS. First Aid for the USMLE Step 2 CK. McGraw-Hill Medical; 2009.
  • 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.
  • 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.
  • Brubaker PH, Kitzman DW. Chronotropic Incompetence: Causes, Consequences, and Management. Circulation. 2011; 123(9): pp. 1010–1020. doi: 10.1161/circulationaha.110.940577.
  • Sinz E et al. ACLS for Experienced Providers. American Heart Association; 2013.
  • Kusumoto, et al. 2018 Guidelines Made Simple: Bradycardia and Cardiac Conduction Dela. https://www.acc.org/guidelines/hubs/bradycardia-and-cardiac-conduction-delay. Accessed January 14, 2020.
  • Scherbak D, Hicks GJ. Left Bundle Branch Block (LBBB). StatPearls. 2019. pmid: 29489192.
  • Soos, McComb. Sinus Arrhythmia. StatPearls. 2019. pmid: 30725696.
  • Issa ZF, Miller JM, Zipes DP. Clinical Arrhythmology and Electrophysiology. Elsevier Health Sciences; 2012.
last updated 07/27/2020
{{uncollapseSections(['4Y13620', 'fV1kFf0', 'W31Phg0', 'TV16Ff0', 'cR1aNg0', 'ae1Qxf0'])}}