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...
...luation of Bradycardia and Conduction Disease...
...e 2. Initial Evaluation of Suspected or Docume...
...l Evaluation of Suspected Atrioventricul...
...tions That Can Induce/Exacerbate Bradycardi...
Table 2. Conditions Associated With Bradycardia a...
...4.2.2. Exe...
...with suspected chronotropic incompetence,...
...s with exercise-related symptoms suspicious...
...4.2.3. Ambulatory...
...evaluation of patients with documen...
...le 3. Cardiac Rhythm Monitors...
...4.2.4. Car...
...n patients with newly identified LBBB, second-d...
...selected patients presenting with b...
...selected patients with bradycardia or bund...
...In the evaluation of patients with asym...
...4.2.5. Laborat...
1. In patients with bradycardia, laboratory test...
...4.2.6. Ge...
...in whom a conduction disorder-causat...
...with inherited conduction disease, geneti...
4.2.7. Sl...
...ith documented or suspected bradycardia or conduc...
...ts with sleep-related bradycardia or...
...ho have previously received or are being considere...
...Inv...
...3.1. Implantable Cardiac Monitor in Patients...
4.3.2. Electrophysiology Testing in Patien...
...Bradyca...
.... Acute Management of Reversible Causes for Bradyc...
...cute Bradycardia Algorithm...
...Potentially Reversible or Treatable...
...5.3.2.1. Atropine and...
.... In patients with SND associated with...
...In patients with SND associated with symptoms or...
...ho have undergone heart transplant without evidenc...
...5. Acute Medical Management of Br...
...5.3.2.2. Therapy of B...
...nts with bradycardia associated wit...
...ts with bradycardia associated with s...
...ith bradycardia associated with symp...
...5.3.2.3. Ther...
...ith bradycardia associated with symptoms or h...
...tients with bradycardia associated with s...
...5.3.2.4. Theophyl...
1. In post-heart transplant patients, aminoph...
.... In patients with SND associated with symptoms...
...5.3.3. Tem...
...ients with persistent hemodynamically unsta...
.... In patients with SND with severe symptoms or he...
...nts with SND with minimal and/or infrequent sympto...
...re 5. Acute Pacing Algorithm
...5.4.1. Gener...
...mptomatic individuals with sinus brad...
...ith sleep-related sinus bradycardia or transie...
.... In patients with asymptomatic SND, or in th...
...presenting with symptomatic SND secondary t...
...5.4.3. Ad...
...In patients with symptoms suggestive of brady...
2. In symptomatic patients with suspected S...
3. In patients with asymptomatic sinus...
...5.4...
...ents with symptoms that are directly attribut...
...n patients who develop symptomatic...
...or patients with tachy-brady syndrome and sympto...
...ts with symptomatic chronotropic incom...
5. In patients with symptoms that are lik...
...5.4.4.1 Perman...
...omatic patients with SND, atrial-based pac...
...symptomatic patients with SND and intac...
...symptomatic patients with SND who have...
...ptomatic patients with SND in which frequen...
...nic SND Management Algorithm...
...Etiology of Atrioventricular Block Co...
...Acute Managem...
6...
...transient or reversible causes of...
...In selected patients with symptomatic secon...
...patients with second-degree or third-de...
...with symptomatic second-degree or th...
...6.3.2. Acute Med...
...s with second-degree or third-degree atrioventr...
...ents with second-degree or third-degr...
.... For patients with second-degree or third-degre...
...6.3.3. Temporary P...
...nts with second-degree or third-degree...
...For patients who require prolonged t...
...nts with second-degree or third-degree atrioventr...
...gement of Bradycardia or Pauses Attributable...
...6.4.1. Gene...
...patients with first-degree atrioventricu...
...matic patients with first-degree atrio...
...6.4....
...with symptomatic atrioventricular block attribut...
...ients who had acute atrioventricular block at...
...with asymptomatic vagally mediated atrioven...
...6.4.3. Additional Test...
...ents with symptoms (e.g., lightheadedness, dizzin...
.... In patients with exertional symptoms (e.g., che...
...atients with second-degree atrioventricular b...
...cted patients with second-degree atrioventri...
...6.4...
...ients with acquired second-degree Mobitz type I...
...ts with neuromuscular diseases asso...
...s with permanent AF and symptomati...
4. In patients who develop symptomatic at...
...patients with an infiltrative cardiomyopath...
...patients with lamin A/C gene mutations, includ...
...s with marked first-degree or second-degree...
.... In patients with neuromuscular dise...
...6.4.4.1....
1. In patients with SND and atrioventricular b...
...atients with atrioventricular block wh...
...patients in sinus rhythm with a single chamb...
...In patients with atrioventricular block who ha...
5. In patients with atrioventricul...
...In patients with atrioventricular block at...
...In patients with permanent or persi...
...Conduction D...
...7.4. Ev...
...atients with newly detected LBBB, a trans...
...tic patients with conduction system dise...
...ted patients presenting with intravent...
...ith symptoms suggestive of intermittent bra...
...n selected patients with LBBB in whom...
...elected asymptomatic patients with...
...n selected asymptomatic patients with LBBB in...
...7.5. Man...
...with syncope and bundle branch block wh...
...ents with alternating bundle branch block, perman...
...ts with Kearns-Sayre syndrome and con...
...patients with Anderson-Fabry disease and...
...patients with heart failure, a mil...
...symptomatic patients with isolated conduction...
...ation of Conduction Disorders Algorithm...
...e 9. Management of Conduction Disorders...
...Speci...
...8.1.1. Patients...
.... In patients who are thought to be at high risk...
...atients with LBBB who require pulmonary artery cat...
...8.1.2.1. Pacin...
...ients who have new postoperative SND or at...
...In patients undergoing isolated coronary artery...
...nts undergoing coronary artery bypass sur...
...undergoing surgery for AF, routine placement...
...ients who have new postoperative SND or...
...atients undergoing surgery for AF who will lik...
...8.1.2...
.... In patients undergoing surgical aortic...
...patients who have new postoperative SN...
...ents undergoing aortic valve surgery who will like...
...n patients who have new postoperativ...
...patients undergoing mitral valve sur...
...n patients undergoing surgical mitral val...
...8.1.2.3.3. Pacing A...
...n patients undergoing tricuspid valve s...
...tients who have new postoperative SND or atri...
...n patients who are undergoing tricuspid...
...8.1.2.4. Condu...
...patients who have new atrioventricular...
...s with new persistent bundle branch bl...
...In patients with new persistent LBBB after tra...
...8.1.2.5.2...
...s with second-degree Mobitz type II atriove...
...ted patients with hypertrophic cardiomyopathy...
...patients with hypertrophic cardiomyopathy who u...
...s with hypertrophic cardiomyopathy, evalu...
...8.2. Management of...
...s with adult congenital heart disease...
...In adults with ACHD and symptomatic bradyc...
...dults with congenital complete atrioventricul...
...dults with ACHD and postoperative second-deg...
...symptomatic adults with congenital complete a...
...with repaired ACHD who require permanent pac...
...s with ACHD with preexisting sinus node and/or...
...th ACHD and pacemakers, atrial-based perma...
...selected adults with ACHD and venous...
...8.3. Management...
...nts presenting with an acute MI, temporary pacing...
...who present with SND or atrioventricular block in...
...s presenting with an acute MI with second d...
...with an acute MI with symptomatic or hemodynamic...
...tients with an acute MI and transient atrioventri...
...with an acute MI and a new bundle-branch b...
...8.4.1. Patient...
...with epilepsy associated with seve...
...O...
...9. Management of Br...
...n patients who require permanent pacing therap...
...11. Shared Decision-M...
...n patients with symptomatic bradycardi...
...s considering implantation of a pacemaker or wi...
...n patients with indications for permanent paci...
.... Discontinuation of Pacemaker Therapy...