bradyarrhythmia (bradycardia)
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Introduction
A disturbances in cardiac rhythm that result in an abnormally slow heart rate, usually under 60/min.
Etiology
- decreased sinus node automaticity (sinus bradycardia)
- sinus node exit block
- atrioventricular block
- pharmaceutical agents
Pathology
- sinus node dysfunction is most often related to age-dependent progressive fibrosis
Diagnostic procedures
Management
as indicated
- assess, Airway, Breathing, Circulation (ABCs)
- administer oxygen
- establish IV access
- 12 lead ECG
- asymptomatic
- type II second degree AV block or type 3 heart block
- transvenous pacer
- transcutaneous pacemaker until transvenous pacemaker can be inserted
- 1st degree or type 1 second degree AV block
- discontinue culprit medications as feasible, observe[3]
- type II second degree AV block or type 3 heart block
- symptomatic (related to bradycardia)
- atropine 0.5 mg IV push every 3-5 min up to 3 mg
- unlikely to be useful for wide-complex bradyarrhythmia
- transcutaneous pacemaker (uncomfortable)
- transvenous pacing is less uncomfortable (patient stable)
- a & b unsuccessful/unavailable
- dopamine 5-20 ug/kg/min (IIb intervention)
- epinephrine 2-20 ug/min (IIb intervention)
- isoproterenol 2-10 ug/min (not indicated in cardiac arrest)
- permanent pacemaker
- atropine 0.5 mg IV push every 3-5 min up to 3 mg
- other recommendations[5]
- nocturnal bradycardia is common
- evaluate these patients for sleep apnea
- left bundle branch block (LBBB)
- evaluate for structural heart disease echocardiogram
- irreversible second-degree Mobitz type II AV block or third-degree AV block should be paced
- Wenckebach block: paced only if symptoms due to bradycardia
- LV ejection fraction 36-50% with pacing >40% of the time
- cardiac resynchronization therapy or His bundle pacing recommended
- LBBB induced by transcatheter aortic-valve replacement (TAVR) is given a class IIb indication for pacing
- do NOT place pacemaker for asymptomatic bradycardia[6]
- nocturnal bradycardia is common
- patients or their legally defined surrogates have the right to refuse implantation of permanent pacemakers & to withdraw pacing, even if life threatening[5]
More general terms
More specific terms
- asystole
- atrioventricular (AV) block
- sick sinus syndrome; atrial fibrillation with bradyarrhythmia; tachycardia-bradycardia syndrome
- sinoatrial exit block
- sinus bradycardia
- ventricular escape rhythm
Additional terms
References
- ↑ Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 177, 179
- ↑ Medical Knowledge Self Assessment Program (MKSAP) 11, 18. American College of Physicians, Philadelphia 1998, 2018
- ↑ 3.0 3.1 Goldberger JJ et al. Significance of asymptomatic bradycardia for subsequent pacemaker implantation and mortality in patients >60 years of age. Am J Cardiol 2011 Sep 15; 108:857. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21757182
- ↑ Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
- ↑ 5.0 5.1 5.2 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: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. J Am Coll Cardiol. 2018 Oct 31. pii: S0735-1097(18)38984-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30412710
Kusumoto FM, Schoenfeld MH, Barrett C et al. ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay. J Am Coll Cardiol 2018 Nov 6; PMID: https://www.ncbi.nlm.nih.gov/pubmed/30412709 https://www.sciencedirect.com/science/article/pii/S0735109718389848 - ↑ 6.0 6.1 Diederichsen SZ et al. Prevalence and prognostic significance of bradyarrhythmias in patients screened for atrial fibrillation vs usual care: Post hoc analysis of the LOOP randomized clinical trial. JAMA Cardiol 2023 Feb 15; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36790817 PMCID: PMC9932940 Free PMC article https://jamanetwork.com/journals/jamacardiology/fullarticle/2801362
Schoenfeld MH, Patton KK. Incidental detection of bradycardia by implantable loop recorders - Unintended consequences. JAMA Cardiol 2023 Feb 15; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36790795 https://jamanetwork.com/journals/jamacardiology/fullarticle/2801364 - ↑ Sidhu S, Marine JE. Evaluating and managing bradycardia. Trends Cardiovasc Med. 2020;30:265-272. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31311698