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
...reatment...
.... Evaluation of Bradycardia and Conductio...
.... Initial Evaluation of Suspected or Documen...
...ial Evaluation of Suspected Atrioven...
Table 1. Medications That Can Induce/Exacerbat...
...onditions Associated With Bradycardia...
...cise Electrocardiographic Testing i...
...s with suspected chronotropic incompetenc...
...with exercise-related symptoms susp...
...y Electrocardiography in Patients With Docum...
1. In the evaluation of patients with documented o...
...able 3. Cardiac Rhythm MonitorsHaving...
...ac Imaging in Bradycardia or Conduction D...
...ents with newly identified LBBB, secon...
...d patients presenting with bradycardia or conducti...
3. In selected patients with bradycardia or b...
...valuation of patients with asymptomatic sin...
.... Laboratory Testing in Patients Wi...
...patients with bradycardia, laborat...
....6. Genetic Testing in Documented or Suspected...
.... In patients in whom a conduction disorder-causa...
...patients with inherited conduction disease, gene...
...2.7. Sleep Apnea Evaluation and Trea...
...ts with documented or suspected bradycar...
...with sleep-related bradycardia or c...
...In patients who have previously received or are...
...asive Testi...
...Implantable Cardiac Monitor in Patients With D...
...ectrophysiology Testing in Patients With Doc...
...ia Attributable to SND...
...ute Management of Reversible Causes for Brad...
...Acute Bradycardia Algorithm...
...Potentially Reversible or Treatable Causes o...
...pine and Beta Agonists for Bradycardia Attribut...
...patients with SND associated with symptoms or...
...patients with SND associated with symptom...
...patients who have undergone heart transplant with...
...edical Management of Bradycardia Attribu...
...Therapy of Beta Blocker and Calcium Channel B...
...with bradycardia associated with symptoms or hem...
...atients with bradycardia associated...
...with bradycardia associated with symp...
...herapy of Digoxin Mediated Bradycardia Attrib...
...ients with bradycardia associated with sy...
...tients with bradycardia associated...
...4. Theophylline/Aminophylline for Bradycardia A...
...rt transplant patients, aminophylline or theo...
2. In patients with SND associated with s...
.... Temporary Pacing for Bradycardia Attributable t...
...tients with persistent hemodynamically unstable...
...s with SND with severe symptoms or hemodynamic...
...ients with SND with minimal and/or infreque...
...gure 5. Acute Pacing Algorithm...
...sive Testing
...l Principles of Chronic Therapy/Management of Br...
...ptomatic individuals with sinus bradycardia or s...
...tients with sleep-related sinus brady...
...nts with asymptomatic SND, or in those in wh...
...ent/Reversible Causes (Including Medicat...
.... Patients presenting with symptomatic SND...
...Additional Testing of Bradycardia Attribu...
...with symptoms suggestive of bradycardia (e.g., s...
...omatic patients with suspected SND, EPS for th...
...ents with asymptomatic sinus bradycardia,...
...4.4. Permanent Pacing for Chronic Therapy/Manag...
...with symptoms that are directly attributa...
.... In patients who develop symptomatic...
...s with tachy-brady syndrome and symptoms attribut...
...patients with symptomatic chronotropic in...
...In patients with symptoms that are likely attr...
...4.1 Permanent Pacing for Chronic Therapy/Mana...
...atic patients with SND, atrial-based...
2. In symptomatic patients with SND and intact a...
...ic patients with SND who have dual chamber pace...
...ic patients with SND in which frequent ventri...
...re 6. Chronic SND Management Alg...
...Etiology of Atrioventricular BlockHaving t...
...Management...
...cute Management of Reversible Causes of...
...Patients with transient or reversible causes...
...ected patients with symptomatic seco...
...patients with second-degree or third-d...
...ith symptomatic second-degree or third-degr...
...dical Therapy for Bradycardia Attributabl...
...nts with second-degree or third-degree atrioventr...
...tients with second-degree or third-degree a...
...with second-degree or third-degree...
...emporary Pacing for Bradycardia At...
...ients with second-degree or third-degree...
...atients who require prolonged tempo...
...ents with second-degree or third-degree atriovent...
...ure 7. Management of Bradycardia or Pauses A...
...ral Principles of Chronic Therapy/Management...
...with first-degree atrioventricular block...
...ic patients with first-degree atrioventricular blo...
...ly Reversible or Transient Causes of Atriovent...
...ith symptomatic atrioventricular block attribu...
...patients who had acute atrioventricular bl...
...ts with asymptomatic vagally mediated...
...tional Testing for Chronic Therapy/Management...
...patients with symptoms (e.g., lightheadedness,...
...atients with exertional symptoms (e.g....
...ected patients with second-degree atrioventricular...
.... In selected patients with second-d...
...Pacing for Chronic Therapy/Management of Bradycar...
...atients with acquired second-degree Mobitz type II...
...s with neuromuscular diseases associated...
...s with permanent AF and symptomatic...
...patients who develop symptomatic atrioventricu...
...ents with an infiltrative cardiomyopathy,...
...nts with lamin A/C gene mutations, inclu...
...ients with marked first-degree or seco...
...with neuromuscular diseases, such as myotonic dys...
...1. Permanent Pacing Techniques and Methods f...
1. In patients with SND and atrioventricular...
.... In select patients with atrioventricular bloc...
...ts in sinus rhythm with a single chamber ve...
.... In patients with atrioventricula...
...s with atrioventricular block who have...
6. In patients with atrioventricular block...
...atients with permanent or persistent AF in...
...isorders (With 1:1 Atrioventricular Conduction)...
...Evaluation of Conduction Disorders (W...
1. In patients with newly detected LBBB...
...c patients with conduction system dise...
...n selected patients presenting with intraventricul...
...atients with symptoms suggestive of in...
...cted patients with LBBB in whom structural hear...
...ted asymptomatic patients with extensiv...
...symptomatic patients with LBBB in whom isc...
.... Management of Conduction Disorders...
...ts with syncope and bundle branch bloc...
...ith alternating bundle branch block, permanent pa...
3. In patients with Kearns-Sayre syndrom...
...atients with Anderson-Fabry disease and...
...patients with heart failure, a mildly t...
...ymptomatic patients with isolated conduction disea...
...tion of Conduction Disorders Algor...
...anagement of Conduction Disorders Algorithm...
...l Populations...
....1. Patients at Risk for Bradycardia During Noncar...
.... In patients who are thought to be at high risk f...
...nts with LBBB who require pulmonary arter...
...1.2.1. Pacing After Isolated Coronary Artery Byp...
...ts who have new postoperative SND or atrioventricu...
...nts undergoing isolated coronary artery bypass s...
.... In patients undergoing coronary artery bypass su...
....2.2. Pacing After Surgery for Atrial Fibrillatio...
...In patients undergoing surgery for AF,...
...ients who have new postoperative SND...
...ients undergoing surgery for AF who will likel...
...ing After Aortic Valve Surgery...
...ndergoing surgical aortic valve replace...
...patients who have new postoperative SND or atr...
3. In patients undergoing aortic val...
...Pacing After Mitral Valve Sur...
...tients who have new postoperative S...
...ients undergoing mitral valve surgery, rou...
...undergoing surgical mitral valve repair...
...Pacing After Tricuspid Valve Surgery...
...ts undergoing tricuspid valve surgery, rout...
...who have new postoperative SND or atr...
...In patients who are undergoing tricuspid valve...
8.1.2.4. Conduction Disturbances After Tran...
...patients who have new atrioventricular bloc...
...ts with new persistent bundle branch...
.... In patients with new persistent LBBB after tran...
...ients Undergoing Surgical Myectomy or Alcohol Sept...
...atients with second-degree Mobitz type...
...patients with hypertrophic cardiomyopathy w...
...ients with hypertrophic cardiomyopathy who unde...
...ients with hypertrophic cardiomyopathy, evaluati...
...of Bradycardia in Adults With Adult...
...dults with adult congenital heart dis...
...th ACHD and symptomatic bradycardia related to atr...
3. In adults with congenital complete atrio...
...th ACHD and postoperative second-degree Mobi...
...asymptomatic adults with congenital complete a...
...ith repaired ACHD who require perma...
...dults with ACHD with preexisting sinus node a...
...with ACHD and pacemakers, atrial-based p...
.... In selected adults with ACHD and venous to...
...agement of Bradycardia in the Context of Acute MI...
...ients presenting with an acute MI,...
...who present with SND or atrioventricular b...
...s presenting with an acute MI with second de...
4. In patients with an acute MI with symptomatic...
...ith an acute MI and transient atrioventricula...
...atients with an acute MI and a new bundle-branch...
...atients With Epilepsy and Symptomatic Bradycardia...
...nts with epilepsy associated with severe...
...Recommendations...
...nagement of Bradycardia and Conduction Tissue...
...n patients who require permanent pac...
...ision-Making for Pacemaker Implantation in the...
...In patients with symptomatic bradycardia or...
...tients considering implantation of a pa...
...with indications for permanent paci...
...3. Discontinuation of Pacemaker Therapy1. In...