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
...eatmen...
...ral Evaluation...
...story and Physical Examination of Patients With D...
...asive Evaluation...
...Electrocardiogram (ECG) in Patients Wi...
Figure 1. Evaluation of Bradycardia and Conductio...
.... Initial Evaluation of Suspected or Docu...
...al Evaluation of Suspected Atrioventricular Block...
...tions That Can Induce/Exacerbate Brad...
...e 2. Conditions Associated With Bradyc...
...Electrocardiographic Testing in Patients With...
...patients with suspected chronotropic i...
...patients with exercise-related symptoms suspic...
.... Ambulatory Electrocardiography in Pati...
.... In the evaluation of patients with docume...
...3. Cardiac Rhythm MonitorsHaving trouble v...
.... Cardiac Imaging in Bradycardia or Conduction...
...In patients with newly identified LBBB, second...
.... In selected patients presenting with br...
...patients with bradycardia or bundle...
...tion of patients with asymptomatic...
...Laboratory Testing in Patients Wi...
...In patients with bradycardia, laboratory tes...
...c Testing in Documented or Suspected Bradycardi...
...ts in whom a conduction disorder-causative m...
...ith inherited conduction disease, gen...
...Sleep Apnea Evaluation and Treatment in...
...ith documented or suspected bradycardia or conduct...
...ith sleep-related bradycardia or conduction disor...
...In patients who have previously received or...
...sive Testing
...table Cardiac Monitor in Patients With D...
.... Electrophysiology Testing in Pat...
...adycardia Attributable...
....3.1. Acute Management of Reversible...
Figure 4. Acute Bradycardia AlgorithmColo...
...ommon Potentially Reversible or Treatable C...
....3.2.1. Atropine and Beta Agonists for Brady...
...nts with SND associated with sympto...
...ents with SND associated with symptoms or hemodyna...
...tients who have undergone heart transplant without...
...te Medical Management of Bradycardia Att...
....3.2.2. Therapy of Beta Blocker and...
...ents with bradycardia associated with sym...
...ients with bradycardia associated with sympto...
...tients with bradycardia associated with sy...
...Therapy of Digoxin Mediated Bradycardia Attri...
...ts with bradycardia associated with sym...
...ts with bradycardia associated with sy...
...hylline/Aminophylline for Bradycar...
.... In post-heart transplant patients...
...atients with SND associated with symptoms...
.... Temporary Pacing for Bradycardia Attribut...
...patients with persistent hemodynam...
...In patients with SND with severe symptoms o...
...with SND with minimal and/or infrequent symptoms...
...te Pacing AlgorithmColors correspond t...
...nvasive Testi...
....1. General Principles of Chronic The...
...asymptomatic individuals with sinus bradycardi...
2. In patients with sleep-related si...
...tients with asymptomatic SND, or in those in w...
...2. Transient/Reversible Causes (Including...
...resenting with symptomatic SND secondary to a reve...
...nal Testing of Bradycardia Attributable to SND...
...tients with symptoms suggestive of bra...
...symptomatic patients with suspected SND, EPS f...
...patients with asymptomatic sinus bradycardia, an...
...4.4. Permanent Pacing for Chronic Therapy...
1. In patients with symptoms that are directly a...
.... In patients who develop symptomatic sinus...
...atients with tachy-brady syndrome and sympt...
...patients with symptomatic chronotropic incom...
...In patients with symptoms that are...
....1. Permanent Pacing Techniques and Methods for C...
...In symptomatic patients with SND, atrial-bas...
...mptomatic patients with SND and int...
3. In symptomatic patients with SND who have du...
...tomatic patients with SND in which frequent...
...re 6. Chronic SND Management Algor...
...Etiology of Atrioventricular BlockHaving troubl...
...ute Manageme...
...Acute Management of Reversible Cau...
...ith transient or reversible causes of atriove...
...atients with symptomatic second-deg...
3. In patients with second-degree or thir...
...nts with symptomatic second-degree or th...
6.3.2. Acute Medical Therapy for Bradycardia Attri...
.... For patients with second-degree or third-deg...
...For patients with second-degree or third-degree a...
...patients with second-degree or third-...
...Temporary Pacing for Bradycardia At...
...atients with second-degree or third-d...
...For patients who require prolonge...
...r patients with second-degree or third-degree...
...ment of Bradycardia or Pauses Attr...
...rinciples of Chronic Therapy/Management...
...n patients with first-degree atrioventricular bloc...
...In asymptomatic patients with first-deg...
...2. Potentially Reversible or Transient...
...with symptomatic atrioventricular block attr...
...ients who had acute atrioventricular block at...
...ients with asymptomatic vagally mediated a...
...3. Additional Testing for Chronic Therapy...
.... In patients with symptoms (e.g., lighth...
...atients with exertional symptoms (e.g....
...In selected patients with second-degr...
...elected patients with second-degre...
6.4.4. Permanent Pacing for Chronic Therapy/Manag...
...ith acquired second-degree Mobitz type I...
...with neuromuscular diseases associated with c...
...nts with permanent AF and symptomatic...
4. In patients who develop symptomatic atrioventri...
...ents with an infiltrative cardiomyopathy, such...
...ents with lamin A/C gene mutations, including l...
...s with marked first-degree or second-degree Mo...
...nts with neuromuscular diseases, such as...
...1. Permanent Pacing Techniques and Meth...
...with SND and atrioventricular bloc...
...In select patients with atrioventricu...
...ts in sinus rhythm with a single ch...
...ts with atrioventricular block who...
...In patients with atrioventricular block wh...
...nts with atrioventricular block at the leve...
...s with permanent or persistent AF in...
...Disorders (With 1:1 Atrioventricular Condu...
...of Conduction Disorders (With 1:1 Atriovent...
...In patients with newly detected LBBB, a...
...mptomatic patients with conduction...
...selected patients presenting with intrav...
...tients with symptoms suggestive of intermitt...
...ed patients with LBBB in whom structural heart...
...selected asymptomatic patients with e...
7. In selected asymptomatic patients with LBBB in...
...Management of Conduction Disorders (With...
...ients with syncope and bundle branch b...
...ients with alternating bundle branch block, perman...
...nts with Kearns-Sayre syndrome and conduction...
...patients with Anderson-Fabry diseas...
...nts with heart failure, a mildly to mod...
6. In asymptomatic patients with isolated condu...
...uation of Conduction Disorders Algorith...
...gure 9. Management of Conduction Disorder...
Special Populat...
...Patients at Risk for Bradycardia Du...
...ts who are thought to be at high r...
...ith LBBB who require pulmonary arter...
...2.1. Pacing After Isolated Coronar...
...patients who have new postoperative SND or atriov...
...atients undergoing isolated coronary artery byp...
...In patients undergoing coronary artery...
...acing After Surgery for Atrial Fibrillat...
...tients undergoing surgery for AF, routine place...
...ho have new postoperative SND or atriovent...
...undergoing surgery for AF who will lik...
...2.3.1. Pacing After Aortic Valve...
...In patients undergoing surgical aort...
...ts who have new postoperative SND or atrioventri...
3. In patients undergoing aortic valv...
...Pacing After Mitral Valve Surgery...
...tients who have new postoperative SND or atriovent...
...undergoing mitral valve surgery, routine pl...
...s undergoing surgical mitral valve repair...
8.1.2.3.3. Pacing After Tricuspid...
.... In patients undergoing tricuspid valve su...
...ents who have new postoperative SND or atri...
...patients who are undergoing tricus...
....1.2.4. Conduction Disturbances After Trans...
...ho have new atrioventricular block after transcat...
...ith new persistent bundle branch b...
...s with new persistent LBBB after t...
...5.2. Patients Undergoing Surgical Myectomy or Alco...
...ith second-degree Mobitz type II atrioventricula...
...selected patients with hypertrophic cardi...
.... In patients with hypertrophic cardiomyopa...
...atients with hypertrophic cardiomyopat...
...gement of Bradycardia in Adults With Adult Con...
...n adults with adult congenital heart disea...
...adults with ACHD and symptomatic bradycardia relat...
...s with congenital complete atrioventricu...
...adults with ACHD and postoperative seco...
...ic adults with congenital complete atriove...
...ith repaired ACHD who require perma...
...h ACHD with preexisting sinus node and/or atrioven...
...s with ACHD and pacemakers, atrial-based...
...ected adults with ACHD and venous to...
...nagement of Bradycardia in the Context of Acute...
...atients presenting with an acute MI, te...
...ients who present with SND or atrioventricu...
...ients presenting with an acute MI with second...
...ients with an acute MI with symptomatic or hemody...
...with an acute MI and transient atr...
.... In patients with an acute MI and a new b...
...ients With Epilepsy and Symptomatic Brady...
...In patients with epilepsy associated with severe s...
...ther Recommendations
...nagement of Bradycardia and Conduction Tissue Dis...
...In patients who require permanent paci...
...Decision-Making for Pacemaker Implantation...
...In patients with symptomatic bradyc...
...tients considering implantation of a pac...
...tients with indications for permanent...
...uation of Pacemaker Therapy1. In pati...