Evaluation and Management of Patients with Bradycardia and Cardiac Conduction Delay
Key Points
Key Points
- Sinus node dysfunction is most often related to age-dependent progressive fibrosis of the sinus nodal tissue and surrounding atrial myocardium leading to abnormalities of sinus node and atrial impulse formation and propagation and will therefore result in various bradycardic or pause-related syndromes.
- Both sleep disorders of breathing and nocturnal bradycardias are relatively common, and treatment of sleep apnea not only reduces the frequency of these arrhythmias but also may offer cardiovascular benefits. The presence of nocturnal bradycardias should prompt consideration for screening for sleep apnea, beginning with solicitation of suspicious symptoms. However, nocturnal bradycardia is not in itself an indication for permanent pacing.
- The presence of left bundle branch block on electrocardiogram markedly increases the likelihood of underlying structural heart disease and of diagnosing left ventricular systolic dysfunction. Echocardiography is usually the most appropriate initial screening test for structural heart disease, including left ventricular systolic dysfunction.
- In sinus node dysfunction, there is no established minimum heart rate or pause duration where permanent pacing is recommended. Establishing temporal correlation between symptoms and bradycardia is important when determining whether permanent pacing is needed.
- In patients with acquired second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, or third-degree atrioventricular block not caused by reversible or physiologic causes, permanent pacing is recommended regardless of symptoms. For all other types of atrioventricular block, in the absence of conditions associated with progressive atrioventricular conduction abnormalities, permanent pacing should generally be considered only in the presence of symptoms that correlate with atrioventricular block.
- In patients with a left ventricular ejection fraction between 36% to 50% and atrioventricular block, who have an indication for permanent pacing and are expected to require ventricular pacing >40% of the time, techniques that provide more physiologic ventricular activation (e.g., cardiac resynchronization therapy, His bundle pacing) are preferred to right ventricular pacing to prevent heart failure.
- Because conduction system abnormalities are common after transcatheter aortic valve replacement, recommendations on postprocedure surveillance and pacemaker implantation are made in this guideline.
- In patients with bradycardia who have indications for pacemaker implantation, shared decision-making and patient-centered care are endorsed and emphasized in this guideline. Treatment decisions are based on the best available evidence and on the patient’s goals of care and preferences.
- Using the principles of shared decision-making and informed consent/refusal, patients with decision-making capacity or his/her legally defined surrogate has the right to refuse or request withdrawal of pacemaker therapy, even if the patient is pacemaker dependent, which should be considered palliative, end-of-life care, and not physician-assisted suicide. However, any decision is complex, should involve all stakeholders, and will always be patient specific.
- Identifying patient populations that will benefit the most from emerging pacing technologies (e.g., His bundle pacing, transcatheter leadless pacing systems) will require further investigation as these modalities are incorporated into clinical practice.
Definitions
| Term | Definition or Description |
| Sinus node dysfunction (with accompanying symptoms) |
|
| Atrioventricular block |
|
| Conduction tissue disease |
2. rsr′, rsR′, rSR′, or rarely a qR in leads V1 or V2. The R′ or r′ deflection is usually wider than the initial R wave. In a minority of patients, a wide and often notched R wave pattern may be seen in lead V1 and/or V2. 3. S wave of greater duration than R wave or >40 ms in leads I and V6 in adults 4. Normal R peak time in leads V5 and V6 but >50 ms in lead V1 Incomplete RBBB: Same QRS morphology criteria as complete RBBB but with a QRS duration between 110 and 119 ms
2. Broad notched or slurred R wave in leads I, aVL, V5, and V6 and an occasional RS pattern in V5 and V6 attributed to displaced transition of QRS complex 3. Absent Q waves in leads I, V5, and V6, but in the lead aVL, a narrow Q wave may be present in the absence of myocardial pathology 4. R peak time >60 ms in leads V5 and V6 but normal in leads V1, V2, and V3, when small initial R waves can be discerned in the precordial leads 5. ST and T waves usually opposite in direction to QRS
2. Presence of left ventricular hypertrophy pattern 3. R peak time >60 ms in leads V4, V5, and V6 4. Absence of Q wave in leads I, V5, and V6
|
| Maximum predicted heart rate for age calculated as 220 – age (y). | |
Treatment
Treatm...
General Evaluation
...ry and Physical Examination of Patients W...
...nvasive Evaluat...
...ctrocardiogram (ECG) in Patients With Documented...
...1. Evaluation of Bradycardia and Conduction Di...
...gure 2. Initial Evaluation of Suspected...
...Initial Evaluation of Suspected Atrioventri...
...e 1. Medications That Can Induce/E...
...Conditions Associated With Bradycardia and...
...cise Electrocardiographic Testing in Patients Wi...
...patients with suspected chronotropic incompeten...
...ents with exercise-related symptoms suspi...
....2.3. Ambulatory Electrocardiography in Pati...
...the evaluation of patients with documented or s...
...Rhythm MonitorsHaving trouble viewing table? Expa...
...Cardiac Imaging in Bradycardia or Co...
.... In patients with newly identified LBBB, se...
...selected patients presenting with bradycardia or...
3. In selected patients with bradyc...
...n the evaluation of patients with asymptomatic...
....5. Laboratory Testing in Patients With...
...patients with bradycardia, laboratory tests (...
...2.6. Genetic Testing in Documented or...
...tients in whom a conduction disorde...
...ts with inherited conduction disease, genetic...
...nea Evaluation and Treatment in Patients With Do...
...n patients with documented or suspected bradyc...
...with sleep-related bradycardia or co...
3. In patients who have previously receive...
...nvasive Testing
...lantable Cardiac Monitor in Patients With Doc...
...ophysiology Testing in Patients With...
...dia Attributable to SN...
...3.1. Acute Management of Reversible Causes...
.... Acute Bradycardia AlgorithmColors correspond...
Table 4. Common Potentially Reversi...
...Atropine and Beta Agonists for Bradycardia A...
...ts with SND associated with symptoms or hemodynami...
...patients with SND associated with symptom...
...who have undergone heart transplant witho...
.... Acute Medical Management of Bradycard...
....2.2. Therapy of Beta Blocker and Calcium Cha...
...In patients with bradycardia associated...
...patients with bradycardia associated with symp...
...n patients with bradycardia associ...
...3. Therapy of Digoxin Mediated Bradycardia Attrib...
...ents with bradycardia associated with...
...ients with bradycardia associated with sy...
...ophylline/Aminophylline for Bradycardia Attr...
...rt transplant patients, aminophyllin...
...In patients with SND associated with sym...
....3.3. Temporary Pacing for Bradycardia Att...
.... In patients with persistent hemo...
...patients with SND with severe symptom...
...n patients with SND with minimal and...
...igure 5. Acute Pacing AlgorithmColors correspo...
Invasive Testin...
...General Principles of Chronic Therapy/Ma...
...In asymptomatic individuals with sinus bradycardia...
...s with sleep-related sinus bradycardia or transie...
...ts with asymptomatic SND, or in tho...
...sient/Reversible Causes (Including Med...
...esenting with symptomatic SND secondar...
...nal Testing of Bradycardia Attributable to...
...ts with symptoms suggestive of bradycardi...
2. In symptomatic patients with suspected...
3. In patients with asymptomatic sinus...
...Permanent Pacing for Chronic Ther...
...with symptoms that are directly attributable to S...
...n patients who develop symptomatic...
...patients with tachy-brady syndrome and symptoms at...
...atients with symptomatic chronotropic incompe...
...atients with symptoms that are likely att...
5.4.4.1. Permanent Pacing Techniques and M...
...In symptomatic patients with SND, atrial-b...
...ptomatic patients with SND and intact a...
...tic patients with SND who have dual ch...
...ic patients with SND in which frequent v...
...igure 6. Chronic SND Management Algorit...
...y of Atrioventricular BlockHaving tro...
...te Managemen...
...Acute Management of Reversible Causes o...
...tients with transient or reversible causes of at...
...ted patients with symptomatic second-degree or t...
...ients with second-degree or third-degree atri...
...patients with symptomatic second-degr...
...ical Therapy for Bradycardia Attributable to...
...For patients with second-degree or t...
.... For patients with second-degree or third-degree...
...with second-degree or third-degree atrio...
...Temporary Pacing for Bradycardia Attributabl...
...For patients with second-degree or thir...
...r patients who require prolonged temporary tr...
...patients with second-degree or third...
...ment of Bradycardia or Pauses Attributable t...
.... General Principles of Chronic Therapy/Man...
...ts with first-degree atrioventricular blo...
...ymptomatic patients with first-degree...
...2. Potentially Reversible or Trans...
...tients with symptomatic atrioventricular b...
...ents who had acute atrioventricular...
...In patients with asymptomatic vagally...
6.4.3. Additional Testing for Chronic The...
1. In patients with symptoms (e.g., lightheadedne...
...tients with exertional symptoms (e.g., chest pai...
...ected patients with second-degree atrioventric...
...atients with second-degree atrioventricular...
...ermanent Pacing for Chronic Therapy/Manageme...
...In patients with acquired second-degree Mobit...
...ents with neuromuscular diseases associated w...
...n patients with permanent AF and symptom...
.... In patients who develop symptomatic atr...
...In patients with an infiltrative cardiomyopa...
6. In patients with lamin A/C gene mutations,...
...ents with marked first-degree or second-degree Mob...
...s with neuromuscular diseases, such as...
...rmanent Pacing Techniques and Methods for C...
...with SND and atrioventricular block who require...
...tients with atrioventricular block...
...For patients in sinus rhythm with...
...ts with atrioventricular block who ha...
...In patients with atrioventricular...
...ts with atrioventricular block at the level of the...
...patients with permanent or persistent A...
...ion Disorders (With 1:1 Atrioventricular Conduc...
7.4. Evaluation of Conduction Disorders (Wi...
...tients with newly detected LBBB, a transtho...
...matic patients with conduction system d...
...In selected patients presenting with intraventr...
...nts with symptoms suggestive of intermitt...
...d patients with LBBB in whom structural heart di...
...ected asymptomatic patients with extensive con...
...cted asymptomatic patients with LBBB in...
...gement of Conduction Disorders (With 1:1 Atr...
...In patients with syncope and bundle...
...s with alternating bundle branch block, perman...
...ts with Kearns-Sayre syndrome and cond...
...ith Anderson-Fabry disease and QRS prolongation gr...
...In patients with heart failure, a mildly to mo...
...In asymptomatic patients with isol...
...igure 8. Evaluation of Conduction Diso...
...gement of Conduction Disorders AlgorithmColors...
...ial Populatio...
...at Risk for Bradycardia During Noncardiac Surger...
...s who are thought to be at high ri...
...with LBBB who require pulmonary arte...
....2.1. Pacing After Isolated Coronary Artery...
...In patients who have new postoperative SND or...
...tients undergoing isolated coronary artery...
...ts undergoing coronary artery bypass surgery who w...
...Pacing After Surgery for Atrial Fibrilla...
1. In patients undergoing surgery for AF, rou...
...patients who have new postoperative SND or atriov...
...n patients undergoing surgery for...
...acing After Aortic Valve Surgery
...ts undergoing surgical aortic valve replacement or...
.... In patients who have new postope...
...undergoing aortic valve surgery who will likely...
.... Pacing After Mitral Valve Surg...
...who have new postoperative SND or atrioventr...
...s undergoing mitral valve surgery, routine...
...s undergoing surgical mitral valve r...
...2.3.3. Pacing After Tricuspid Valve Surg...
...ndergoing tricuspid valve surgery, rout...
...patients who have new postoperative SND or a...
...ents who are undergoing tricuspid valve replacemen...
8.1.2.4. Conduction Disturbances After...
...s who have new atrioventricular block...
...patients with new persistent bundle bran...
...s with new persistent LBBB after tra...
...2. Patients Undergoing Surgical Myectomy or Alcoh...
...patients with second-degree Mobitz type II...
...patients with hypertrophic cardio...
...patients with hypertrophic cardiomyo...
...patients with hypertrophic cardiomyopa...
....2. Management of Bradycardia in Adults...
1. In adults with adult congenital heart...
...n adults with ACHD and symptomatic bradycardia...
...lts with congenital complete atrioventricular b...
...with ACHD and postoperative second-degree Mobit...
5. In asymptomatic adults with conge...
...ith repaired ACHD who require perm...
7. In adults with ACHD with preexistin...
...ith ACHD and pacemakers, atrial-based...
...adults with ACHD and venous to systemic intracardi...
...3. Management of Bradycardia in the Context of A...
...ients presenting with an acute MI, te...
...who present with SND or atrioventric...
3. In patients presenting with an a...
...ith an acute MI with symptomatic or hemodyn...
.... In patients with an acute MI and transient atr...
.... In patients with an acute MI and a new bundle...
...atients With Epilepsy and Symptomatic...
...In patients with epilepsy associated with severe...
...ther Recommenda...
...t of Bradycardia and Conduction Ti...
...In patients who require permanent p...
...Shared Decision-Making for Pacemaker Implantatio...
...tients with symptomatic bradycardia or conduc...
...considering implantation of a pacemaker or...
...In patients with indications for per...
...3. Discontinuation of Pacemaker Therapy1. In pat...