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). | |
General Evaluation
4.1. History and Physical Examination of Patients With Documented or Suspected Bradycardia or Conduction Disorders
Noninvasive Evaluation
4.2.1. Electrocardiogram (ECG) in Patients With Documented or Suspected Bradycardia or Conduction Disorders
Treatment
Treatm...
...ation of Bradycardia and Conduction Di...
...re 2. Initial Evaluation of Suspected or Documente...
...tial Evaluation of Suspected Atrioventricular Blo...
.... Medications That Can Induce/Exacerbate Bradyc...
...Conditions Associated With Bradycardia and Co...
....2.2. Exercise Electrocardiographic Test...
...n patients with suspected chronotropic i...
...with exercise-related symptoms suspicious for bra...
...ory Electrocardiography in Patients With Document...
...ation of patients with documented or...
...rdiac Rhythm MonitorsHaving trouble viewing t...
...Imaging in Bradycardia or Conduction...
...patients with newly identified LBBB, second...
...elected patients presenting with bradyc...
...selected patients with bradycardia or bundle bra...
...n the evaluation of patients with asy...
...oratory Testing in Patients With Documented o...
...tients with bradycardia, laboratory tests (e...
...esting in Documented or Suspected Brad...
...n whom a conduction disorder-causative mutati...
...atients with inherited conduction dise...
...Sleep Apnea Evaluation and Treatme...
1. In patients with documented or suspected brad...
...with sleep-related bradycardia or conduction d...
...s who have previously received or are...
...asive Testing
...le Cardiac Monitor in Patients With Documented...
....2. Electrophysiology Testing in Pati...
...cardia Attributable to SND...
...anagement of Reversible Causes for Brady...
...gure 4. Acute Bradycardia A...
...mon Potentially Reversible or Treatable...
...tropine and Beta Agonists for Bradycardia Attribu...
...ith SND associated with symptoms or h...
...In patients with SND associated with symptoms o...
.... In patients who have undergone heart transpla...
...e 5. Acute Medical Management of Br...
...Therapy of Beta Blocker and Calcium Channel...
...nts with bradycardia associated with...
...n patients with bradycardia associated...
...In patients with bradycardia associated wit...
...herapy of Digoxin Mediated Bradycardi...
...In patients with bradycardia associated with symp...
...s with bradycardia associated with sympto...
...4. Theophylline/Aminophylline for B...
...transplant patients, aminophylline or theophylli...
...tients with SND associated with sympt...
...rary Pacing for Bradycardia Attributa...
1. In patients with persistent hemod...
...nts with SND with severe symptoms or hemodynam...
...atients with SND with minimal and/or infreque...
...Acute Pacing Algorith...
Invasive Tes...
....1. General Principles of Chronic Ther...
...omatic individuals with sinus bradyca...
.... In patients with sleep-related sinu...
...ients with asymptomatic SND, or in those in whom...
...ransient/Reversible Causes (Including Med...
...tients presenting with symptomatic SND secondar...
...3. Additional Testing of Bradycardia Attributable...
.... In patients with symptoms suggestive of bradyc...
...In symptomatic patients with suspected SND, EP...
.... In patients with asymptomatic sinus br...
...rmanent Pacing for Chronic Therapy/Manage...
...In patients with symptoms that are directly at...
...ts who develop symptomatic sinus bradycardia a...
...nts with tachy-brady syndrome and sympt...
...In patients with symptomatic chronotropic...
...patients with symptoms that are likel...
...ermanent Pacing for Chronic Therapy/...
...c patients with SND, atrial-based p...
...symptomatic patients with SND and intact atri...
...ymptomatic patients with SND who have dual chambe...
...In symptomatic patients with SND in which...
...e 6. Chronic SND Management Algorithm...
...logy of Atrioventricular BlockHaving trouble...
...Management
...3.1. Acute Management of Reversible Causes...
...Patients with transient or reversible...
.... In selected patients with symptomatic second...
...patients with second-degree or third...
.... In patients with symptomatic second-de...
...cute Medical Therapy for Bradycardia Attributab...
...with second-degree or third-degree a...
...ents with second-degree or third-degree atrio...
...s with second-degree or third-degree atriov...
...Pacing for Bradycardia Attributable to A...
...s with second-degree or third-degree a...
...For patients who require prolonged temporary...
...r patients with second-degree or third-de...
...agement of Bradycardia or Pauses Attri...
...ral Principles of Chronic Therapy/Manageme...
...n patients with first-degree atrioventricular b...
...tic patients with first-degree atrioventricular bl...
...lly Reversible or Transient Causes of Atriove...
...ents with symptomatic atrioventricular block...
...ients who had acute atrioventricular block...
...ients with asymptomatic vagally mediated at...
...4.3. Additional Testing for Chronic Th...
...ients with symptoms (e.g., lighthe...
...s with exertional symptoms (e.g., ches...
...elected patients with second-degree atrioven...
...In selected patients with second-deg...
...4.4. Permanent Pacing for Chronic Therapy/Ma...
...patients with acquired second-degr...
...ients with neuromuscular diseases associated...
...ents with permanent AF and symptomatic bradyc...
...patients who develop symptomatic atrioventricul...
...atients with an infiltrative cardiomyopathy,...
...with lamin A/C gene mutations, including limb-gi...
...In patients with marked first-degree...
.... In patients with neuromuscular diseases, such...
...Permanent Pacing Techniques and Methods for Chro...
.... In patients with SND and atrioventricular bl...
.... In select patients with atrioventricula...
...or patients in sinus rhythm with a...
...patients with atrioventricular bl...
5. In patients with atrioventricula...
...In patients with atrioventricular bloc...
...In patients with permanent or persistent AF...
...sorders (With 1:1 Atrioventricular Co...
...n of Conduction Disorders (With 1:1 Atrioventric...
...ients with newly detected LBBB, a transtho...
...omatic patients with conduction system disease, i...
3. In selected patients presenting...
...nts with symptoms suggestive of intermi...
.... In selected patients with LBBB in whom structu...
...selected asymptomatic patients wit...
...n selected asymptomatic patients with LBBB in...
...of Conduction Disorders (With 1:1 A...
...with syncope and bundle branch block who a...
...ents with alternating bundle branch block, perm...
...ients with Kearns-Sayre syndrome and c...
...ith Anderson-Fabry disease and QRS pro...
...ith heart failure, a mildly to moderately reduced...
...tic patients with isolated conduction disease and...
...ation of Conduction Disorders Algori...
.... Management of Conduction Disorders A...
...al Population...
.... Patients at Risk for Bradycardia Dur...
...ho are thought to be at high risk for the...
.... In patients with LBBB who require pulmonary art...
...After Isolated Coronary Artery Bypass Su...
...who have new postoperative SND or a...
.... In patients undergoing isolated cor...
...undergoing coronary artery bypass...
...1.2.2. Pacing After Surgery for Atria...
1. In patients undergoing surgery for AF...
...In patients who have new postoperati...
...n patients undergoing surgery for AF who wi...
8.1.2.3.1. Pacing After Aortic Valve...
...undergoing surgical aortic valve replacem...
...nts who have new postoperative SND or atriove...
...patients undergoing aortic valve surgery who w...
...2. Pacing After Mitral Valve Surgery...
.... In patients who have new postope...
...s undergoing mitral valve surgery, routine pla...
...undergoing surgical mitral valve repair or...
...3. Pacing After Tricuspid Valve...
...ents undergoing tricuspid valve surgery...
...tients who have new postoperative SND or a...
...ents who are undergoing tricuspid valv...
....1.2.4. Conduction Disturbances After...
...who have new atrioventricular block after tra...
...patients with new persistent bund...
...ts with new persistent LBBB after transc...
.... Patients Undergoing Surgical Myectomy...
...ients with second-degree Mobitz ty...
...selected patients with hypertrophic cardiomyo...
.... In patients with hypertrophic cardiomyopa...
...ith hypertrophic cardiomyopathy, e...
...of Bradycardia in Adults With Adult Congeni...
...lts with adult congenital heart disease (ACHD)...
2. In adults with ACHD and symptomatic br...
...lts with congenital complete atrioventr...
4. In adults with ACHD and postoperative second...
...omatic adults with congenital complete...
...In adults with repaired ACHD who require permane...
...ults with ACHD with preexisting sinus node and/or...
...In adults with ACHD and pacemakers,...
...lected adults with ACHD and venous to sys...
...ment of Bradycardia in the Context of Acute MI...
...presenting with an acute MI, temporary pacing is...
.... Patients who present with SND or atr...
.... In patients presenting with an acute MI wit...
...ts with an acute MI with symptomatic or h...
.... In patients with an acute MI and transi...
...ents with an acute MI and a new bundle...
...1. Patients With Epilepsy and Symptomatic Bradyca...
...with epilepsy associated with severe symptom...
...r Recommendations
...of Bradycardia and Conduction Tissue Dise...
...n patients who require permanent pacing ther...
...Decision-Making for Pacemaker Implantation...
...ents with symptomatic bradycardia or con...
...nsidering implantation of a pacemaker or...
.... In patients with indications for...
...continuation of Pacemaker Therapy1. In...