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
...Treatment...
...1. Evaluation of Bradycardia and Conduc...
...al Evaluation of Suspected or Documented SND Alg...
...e 3. Initial Evaluation of Suspected Atr...
...Medications That Can Induce/Exacerbate Bradycard...
...onditions Associated With Bradycardia and Co...
...4.2.2. Exer...
1. In patients with suspected chronotropic i...
...ith exercise-related symptoms suspicious for bra...
...4.2.3. Ambulat...
...the evaluation of patients with documented or su...
.... Cardiac Rhythm MonitorsHaving troub...
...4.2.4. Car...
.... In patients with newly identified LBBB, se...
...ted patients presenting with bradycardia or c...
...ected patients with bradycardia or bund...
...uation of patients with asymptomatic s...
...4.2.5....
...with bradycardia, laboratory tests (e.g., thyroi...
...4.2.6. Gen...
...In patients in whom a conduction disorde...
...patients with inherited conduction...
...4.2.7. Sleep...
...In patients with documented or sus...
...ents with sleep-related bradycardia or co...
...s who have previously received or are being...
...Invasive...
...antable Cardiac Monitor in Patients W...
...ctrophysiology Testing in Patients With Documented...
...Bradycardia At...
....1. Acute Management of Reversible Causes f...
...cute Bradycardia Algorithm...
.... Common Potentially Reversible or T...
...5.3.2.1...
1. In patients with SND associated with sympt...
...ts with SND associated with sympto...
...nts who have undergone heart trans...
...5. Acute Medical Management of Bradycardia...
...5.3.2.2. The...
...with bradycardia associated with symptoms or h...
...s with bradycardia associated with sy...
...In patients with bradycardia associated...
...5.3.2.3. Ther...
...atients with bradycardia associated with sy...
...with bradycardia associated with symptoms or...
...5.3.2.4. T...
1. In post-heart transplant patients, am...
...ts with SND associated with symptom...
...5.3.3. T...
.... In patients with persistent hemody...
...n patients with SND with severe symptoms...
...atients with SND with minimal and/o...
...Acute Pacing Algorithm...
...Invas...
...5.4.1. General Princip...
...symptomatic individuals with sinus brad...
...atients with sleep-related sinus brad...
...tients with asymptomatic SND, or in those i...
...5.4.2. Trans...
...presenting with symptomatic SND secondary to a re...
...5.4.3. Addition...
...patients with symptoms suggestive of bradycardia (...
...ptomatic patients with suspected SND, EPS for th...
...ith asymptomatic sinus bradycardia, an EPS sho...
...5.4.4. Perma...
1. In patients with symptoms that are directly a...
...atients who develop symptomatic sinus bradycard...
...r patients with tachy-brady syndrome and sympto...
...ith symptomatic chronotropic incompetence,...
...with symptoms that are likely attributable...
...5.4.4.1 Permanent Pacing...
...c patients with SND, atrial-based pacing is recom...
...mptomatic patients with SND and intact atr...
...tic patients with SND who have dual chamber pace...
...mptomatic patients with SND in which frequent...
...onic SND Management Algorithm...
...ogy of Atrioventricular BlockHaving trouble...
...6.3.1. Acute M...
...with transient or reversible causes of atrio...
...ed patients with symptomatic second-degree or...
...s with second-degree or third-degree atriovent...
...patients with symptomatic second-degree...
...6.3.2....
...with second-degree or third-degre...
2. For patients with second-degree or...
...atients with second-degree or third-degre...
...6.3.3....
...ients with second-degree or third-d...
2. For patients who require prolonged tempo...
.... For patients with second-degree or third-degre...
Figure 7. Management of Bradycardia...
...6.4.1. General...
...n patients with first-degree atrioven...
...n asymptomatic patients with first-degree atri...
...6.4.2. Pot...
...nts with symptomatic atrioventricular block a...
...n patients who had acute atrioventri...
...ients with asymptomatic vagally mediated atriov...
...6.4.3. Additi...
...patients with symptoms (e.g., lighthe...
2. In patients with exertional symptom...
...ected patients with second-degree atrioventricular...
...selected patients with second-degree a...
6.4.4....
...ts with acquired second-degree Mobitz...
...nts with neuromuscular diseases associated wi...
...In patients with permanent AF and symptomat...
...ients who develop symptomatic atrioventricular...
...ients with an infiltrative cardiom...
...with lamin A/C gene mutations, inc...
7. In patients with marked first-d...
...ith neuromuscular diseases, such as my...
6.4.4.1...
1. In patients with SND and atriov...
2. In select patients with atrioventricular...
...in sinus rhythm with a single chamber ve...
4. In patients with atrioventricular blo...
...nts with atrioventricular block who have an i...
...patients with atrioventricular block at the...
...patients with permanent or persistent...
...Conduction Disorders (...
...7.4. Evaluat...
...with newly detected LBBB, a transthoracic e...
...mptomatic patients with conduction system dis...
...selected patients presenting with...
...atients with symptoms suggestive of int...
...elected patients with LBBB in whom structura...
...n selected asymptomatic patients with...
...d asymptomatic patients with LBBB...
...7.5. Man...
...n patients with syncope and bundle branch block...
...ents with alternating bundle branch block,...
.... In patients with Kearns-Sayre syndrome and condu...
...ts with Anderson-Fabry disease and QRS prolon...
...nts with heart failure, a mildly to mod...
...In asymptomatic patients with isolated conduct...
...valuation of Conduction Disorders Algorithm...
...gement of Conduction Disorders Algorithm...
...Special Populations...
...8.1.1. Patients...
...ts who are thought to be at high risk for the dev...
...In patients with LBBB who require pulmonary artery...
...8.1.2.1. Pacing...
...tients who have new postoperative...
...atients undergoing isolated coronary...
3. In patients undergoing coronary arter...
...8.1.2.2. P...
...ndergoing surgery for AF, routine plac...
...ho have new postoperative SND or atr...
...ts undergoing surgery for AF who will...
...8.1.2.3...
...atients undergoing surgical aortic valv...
...patients who have new postoperative SND...
...undergoing aortic valve surgery who will li...
...8.1.2.3.2. Paci...
...s who have new postoperative SND or atriove...
2. In patients undergoing mitral valve...
...atients undergoing surgical mitral valve...
...8.1.2.3.3. Pacing A...
...patients undergoing tricuspid valve s...
.... In patients who have new postoperative SND or at...
...s who are undergoing tricuspid valve replac...
...In patients who have new atrioventric...
...In patients with new persistent bun...
...s with new persistent LBBB after transc...
...8.1.2.5.2. Patient...
...with second-degree Mobitz type II atrioven...
.... In selected patients with hypertrophic car...
...s with hypertrophic cardiomyopathy who...
...patients with hypertrophic cardiomyopathy...
...8.2. Managemen...
...h adult congenital heart disease (ACHD) and sympt...
...s with ACHD and symptomatic bradycardia re...
...ts with congenital complete atrioventricula...
...with ACHD and postoperative second-degree Mobitz...
...mptomatic adults with congenital complete atriove...
6. In adults with repaired ACHD who requi...
...dults with ACHD with preexisting sinu...
...adults with ACHD and pacemakers, atr...
...In selected adults with ACHD and venous to...
...8.3. Ma...
...ts presenting with an acute MI, temporary p...
.... Patients who present with SND or atrio...
...atients presenting with an acute MI with s...
...patients with an acute MI with symptomat...
...ts with an acute MI and transient a...
...atients with an acute MI and a new bundl...
...8.4.1. Patients...
...n patients with epilepsy associated...
...Oth...
...9. Management...
...ents who require permanent pacing therapy, b...
...1...
...s with symptomatic bradycardia or co...
...s considering implantation of a pacemaker or wit...
...In patients with indications for perm...
...uation of Pacemaker Therapy1. In pati...