Management of bradycardia

Last updated: November 20, 2023

Summarytoggle arrow icon

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.”

Managementtoggle arrow icon

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

Unstable bradycardiatoggle arrow icon

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]



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

Acute management checklist for unstable bradycardiatoggle arrow icon

Stable bradycardiatoggle arrow icon

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]


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.

Temporary cardiac pacingtoggle arrow icon

Transcutaneous pacing [4][5]

  • Definition: a temporizing treatment for bradyarrhythmias in which electrical impulses are delivered through pacing pads placed on the chest wall to stimulate cardiac contraction
  • Indication: unstable bradycardia for which pharmacotherapy alone either is ineffective, not readily available, or contraindicated
  • Contraindications: no absolute contraindications

Technical background

  • Pacemaker spike: A narrow upward deflection on an ECG tracing caused by an electrical impulse from a pacemaker.
  • Electrical capture
  • Mechanical capture
    • Physical cardiac contraction that occurs when current is conducted from an external pacemaker
    • Manifests as a palpable pulse, a pulse oximetry waveform, or ventricular contraction visible on POCUS.


Landmarks and positioning

Consider placing pacer pads early in patients with bradyarrhythmias at risk of decompensation. [4]

Procedure [4]

  1. Apply pacer pads to the chest.
  2. Connect the cable from the pads to the pacemaker.
  3. Turn on the pacemaker and select the pacer function.
  4. Verify that the pacemaker detects the patient's intrinsic rhythm.
  5. Set the pacing rate higher than the patient's native heart rate (generally 60–70/minute).
  6. Increase the current output until electrical capture occurs. [6]
  7. Confirm mechanical capture clinically or using POCUS.
  8. Maintain the current 5–10 mA above the minimum current required for mechanical capture. [6][7]
  9. Provide procedural sedation for conscious patients, unless there is persistent hemodynamic instability.

In the unconscious or near-arrest patient, start the current at maximum and decrease until capture is lost. Maintain the final output at 5–10 mA above this threshold. [5]

Postprocedural care [5]


Consider the following if electrical capture or mechanical capture is lost:

Complications [4][6]

Transvenous pacing [4]

Causes of bradycardiatoggle arrow icon

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

Etiologies by underlying mechanism

Cause [2][9][10]

Increased vagal tone

Degeneration of the conducting system

Referencestoggle arrow icon

  1. Panchal AR, Bartos JA, Cabañas JG, et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020; 142 (16_suppl_2).doi: 10.1161/cir.0000000000000916 . | Open in Read by QxMD
  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
  4. Kasper DL, Hauser SL, Loscalzo J, Longo DL, Jameson JL, Fauci AS. Harrison's Principles of Internal Medicine Vol 1 20e. McGraw-Hill Education / Medical ; 2018
  5. Dakkak W, Doukky R. Sick Sinus Syndrome. StatPearls. 2019.
  6. Roberts JR. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. Elsevier ; 2018
  7. Reichman EF. Reichman's Emergency Medicine Procedures, 3rd Edition. McGraw Hill Professional ; 2018
  8. Doukky R, Bargout R, Kelly RF, Calvin JE. Using transcutaneous cardiac pacing to best advantage: How to ensure successful capture and avoid complications.. J Crit Illn. 2003; 18 (5): p.219-225.
  9. Reichman EF. Emergency Medicine Procedures, Second Edition. McGraw-Hill Education / Medical ; 2013
  10. Walls R, MD R, Hockberger R, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice. Elsevier ; 2022
  11. Yu VL, Stout JE, Galindo NS. Epidemiology and pathogenesis of Legionella infection. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. Last updated: April 7, 2016. Accessed: August 15, 2016.
  12. Le T, Bhushan V, Bagga HS. First Aid for the USMLE Step 2 CK. McGraw-Hill Medical ; 2009
  13. Sauer WH. Normal Sinus Rhythm and Sinus Arrhythmia. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. Last updated: November 15, 2016. Accessed: February 22, 2017.
  14. Homoud MK. Sinoatrial Nodal Pause, Arrest, and Exit Block. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. Last updated: January 22, 2018. Accessed: April 13, 2018.
  15. 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
  16. Sinz E et al.. ACLS for Experienced Providers. American Heart Association ; 2013
  17. 2018 Guidelines Made Simple: Bradycardia and Cardiac Conduction Dela. . Accessed: January 14, 2020.
  18. Scherbak D, Hicks GJ. Left Bundle Branch Block (LBBB). StatPearls. 2019.
  19. Soos, McComb. Sinus Arrhythmia. StatPearls. 2019.
  20. Issa ZF, Miller JM, Zipes DP. Clinical Arrhythmology and Electrophysiology. Elsevier Health Sciences ; 2012

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