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
Treatme...
General Evaluati...
...ory and Physical Examination of Patients With Do...
...ninvasive Evaluation...
....1. Electrocardiogram (ECG) in Patients W...
...re 1. Evaluation of Bradycardia and Conduction Di...
...igure 2. Initial Evaluation of Susp...
.... Initial Evaluation of Suspected Atrioventric...
...e 1. Medications That Can Induce/Exac...
...tions Associated With Bradycardia and Co...
.... Exercise Electrocardiographic Testin...
.... In patients with suspected chronotropic incompet...
...ients with exercise-related symptoms s...
.... Ambulatory Electrocardiography in Patien...
1. In the evaluation of patients with docume...
...Cardiac Rhythm MonitorsHaving trouble viewing...
...ardiac Imaging in Bradycardia or Conducti...
...with newly identified LBBB, second-...
...d patients presenting with bradycardia...
...cted patients with bradycardia or bund...
...ation of patients with asymptomatic sinus brad...
...Laboratory Testing in Patients With Document...
...with bradycardia, laboratory tests (e.g...
...c Testing in Documented or Suspected Bradycard...
...patients in whom a conduction disord...
...n patients with inherited conduction disea...
...2.7. Sleep Apnea Evaluation and Treatment i...
...with documented or suspected bradycardia or condu...
...s with sleep-related bradycardia or co...
...n patients who have previously rec...
...sive Testing
...lantable Cardiac Monitor in Patients W...
4.3.2. Electrophysiology Testing in Patien...
Bradycardia Attributable to SN...
5.3.1. Acute Management of Reversible Causes f...
.... Acute Bradycardia AlgorithmColors corres...
...Common Potentially Reversible or Treatable Cause...
...1. Atropine and Beta Agonists for Bradycar...
.... In patients with SND associated with symptoms...
...with SND associated with symptoms or hemodynam...
...n patients who have undergone heart transpl...
...5. Acute Medical Management of Bradycardia Attr...
.... Therapy of Beta Blocker and Calcium Chan...
...atients with bradycardia associated w...
...atients with bradycardia associated with sympto...
...patients with bradycardia associat...
...py of Digoxin Mediated Bradycardia Attributable to...
...ith bradycardia associated with symptoms or hemod...
...In patients with bradycardia associated with sy...
...ophylline/Aminophylline for Bradyc...
...st-heart transplant patients, aminophylline...
...patients with SND associated with sy...
...emporary Pacing for Bradycardia Attributa...
...n patients with persistent hemodyn...
...ith SND with severe symptoms or hemody...
...nts with SND with minimal and/or infr...
...ute Pacing AlgorithmColors correspond to C...
...sive Testing...
...Principles of Chronic Therapy/Manageme...
...symptomatic individuals with sinus br...
...s with sleep-related sinus bradycard...
3. In patients with asymptomatic SND, or in those...
...4.2. Transient/Reversible Causes (Including...
...resenting with symptomatic SND secondary to a re...
...ional Testing of Bradycardia Attributable to SND...
...patients with symptoms suggestive of...
...ic patients with suspected SND, EPS fo...
...s with asymptomatic sinus bradycardia, an E...
...Permanent Pacing for Chronic Therapy/Manag...
...n patients with symptoms that are directly attr...
.... In patients who develop symptomat...
...atients with tachy-brady syndrome an...
...ith symptomatic chronotropic incompetence, permane...
...ients with symptoms that are likely at...
...nt Pacing Techniques and Methods for Chron...
...tic patients with SND, atrial-based...
...ymptomatic patients with SND and intact atriov...
...matic patients with SND who have dual chamber pace...
...tic patients with SND in which frequent ven...
...gure 6. Chronic SND Management AlgorithmColors...
...ogy of Atrioventricular BlockHaving trouble view...
...cute Management
...1. Acute Management of Reversible Caus...
...ts with transient or reversible cause...
...ted patients with symptomatic second-degree or t...
...ith second-degree or third-degree atri...
...patients with symptomatic second-degree or third...
...Acute Medical Therapy for Bradycardia Attribut...
...nts with second-degree or third-degree at...
...ents with second-degree or third-degree atrioven...
...nts with second-degree or third-degree atrioventri...
...ary Pacing for Bradycardia Attributable to Atri...
...ts with second-degree or third-degree atrioven...
...patients who require prolonged temporary transven...
...with second-degree or third-degree atrioventric...
...7. Management of Bradycardia or Pauses Attr...
.... General Principles of Chronic Therapy/...
...In patients with first-degree atriovent...
2. In asymptomatic patients with first-deg...
...ally Reversible or Transient Causes of A...
...atients with symptomatic atrioventricu...
...ents who had acute atrioventricular block attribu...
...In patients with asymptomatic vagally mediated a...
.... Additional Testing for Chronic Therapy/Managemen...
1. In patients with symptoms (e.g., lighthea...
...patients with exertional symptoms (e...
...patients with second-degree atrioventricu...
...patients with second-degree atrioventricul...
...nent Pacing for Chronic Therapy/Management of Br...
...In patients with acquired second-degree M...
.... In patients with neuromuscular diseases assoc...
...with permanent AF and symptomatic...
...patients who develop symptomatic atr...
...ith an infiltrative cardiomyopathy, such as card...
...In patients with lamin A/C gene mutations,...
...ith marked first-degree or second-de...
...with neuromuscular diseases, such as myot...
6.4.4.1. Permanent Pacing Technique...
...patients with SND and atrioventricular...
...lect patients with atrioventricular block who r...
...For patients in sinus rhythm with a...
...In patients with atrioventricular block who have...
...nts with atrioventricular block who have...
...tients with atrioventricular block...
...tients with permanent or persistent AF...
...ion Disorders (With 1:1 Atrioventric...
...luation of Conduction Disorders (With 1...
...ients with newly detected LBBB, a transth...
...ic patients with conduction system disease, in who...
...ed patients presenting with intrav...
...In patients with symptoms suggestive o...
.... In selected patients with LBBB in whom structur...
...d asymptomatic patients with extensive conduct...
7. In selected asymptomatic patients...
...ment of Conduction Disorders (With 1:1 A...
...atients with syncope and bundle branch b...
...n patients with alternating bundle bra...
.... In patients with Kearns-Sayre syndrome an...
...s with Anderson-Fabry disease and QRS...
5. In patients with heart failure,...
...asymptomatic patients with isolated con...
...re 8. Evaluation of Conduction Disorder...
Figure 9. Management of Conduction Diso...
...pecial Populatio...
...Patients at Risk for Bradycardia During Noncardia...
...n patients who are thought to be at high ris...
...atients with LBBB who require pulmonary artery c...
...cing After Isolated Coronary Artery Bypass Surge...
...patients who have new postoperative SND...
...atients undergoing isolated coronar...
...undergoing coronary artery bypass surgery who...
...cing After Surgery for Atrial Fibrillation...
...ndergoing surgery for AF, routine plac...
...ts who have new postoperative SND or atri...
...s undergoing surgery for AF who wil...
...1.2.3.1. Pacing After Aortic Valve Surgery...
...In patients undergoing surgical aortic...
...s who have new postoperative SND or atriovent...
...undergoing aortic valve surgery who will likely r...
...3.2. Pacing After Mitral Valve Surgery...
.... In patients who have new postoperative SND or...
...patients undergoing mitral valve surgery, routin...
.... In patients undergoing surgical mitral valve...
...3.3. Pacing After Tricuspid Valve Sur...
...tients undergoing tricuspid valve surgery, routin...
...who have new postoperative SND or atrioventric...
...ts who are undergoing tricuspid valve replacem...
...Conduction Disturbances After Transcatheter A...
...patients who have new atrioventricular block a...
.... In patients with new persistent bundle branch b...
...with new persistent LBBB after tra...
...Patients Undergoing Surgical Myectomy or Alc...
...nts with second-degree Mobitz type I...
...d patients with hypertrophic cardiomyopat...
...ts with hypertrophic cardiomyopathy who underg...
...s with hypertrophic cardiomyopathy, evaluatio...
...ement of Bradycardia in Adults Wit...
...In adults with adult congenital heart disease (ACH...
...with ACHD and symptomatic bradycardia related t...
...dults with congenital complete atri...
...In adults with ACHD and postoperative second-degre...
...ic adults with congenital complete atrio...
...s with repaired ACHD who require permane...
...adults with ACHD with preexisting sin...
...n adults with ACHD and pacemakers, atrial-ba...
...ected adults with ACHD and venous t...
...Management of Bradycardia in the Context of Acut...
...ts presenting with an acute MI, temporar...
...Patients who present with SND or atriove...
.... In patients presenting with an acute...
.... In patients with an acute MI with symp...
...s with an acute MI and transient atriovent...
...ents with an acute MI and a new bundle-bra...
...Patients With Epilepsy and Symptomatic Bradycardi...
...ith epilepsy associated with severe s...
Other Recommenda...
...nt of Bradycardia and Conduction Tissue Disease in...
...In patients who require permanent pacing therapy,...
...ision-Making for Pacemaker Implantation...
...ents with symptomatic bradycardia or conductio...
.... Patients considering implantation of a pacemake...
...tients with indications for permanent...
...Discontinuation of Pacemaker Therapy1. In...