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
...eatment...
Figure 1. Evaluation of Bradycardia and Conduct...
...al Evaluation of Suspected or Documen...
...gure 3. Initial Evaluation of Suspected Atriove...
...tions That Can Induce/Exacerbate B...
...Conditions Associated With Bradycardia and Conduct...
...ise Electrocardiographic Testing i...
...with suspected chronotropic incompetence, exercis...
...with exercise-related symptoms susp...
...y Electrocardiography in Patients With Documented...
.... In the evaluation of patients with documented...
...3. Cardiac Rhythm MonitorsHaving tr...
...iac Imaging in Bradycardia or Conduction Disorder...
...nts with newly identified LBBB, second-de...
...n selected patients presenting with bradycar...
...ted patients with bradycardia or bu...
...e evaluation of patients with asymptomatic sinus b...
...y Testing in Patients With Documented or...
...atients with bradycardia, laboratory...
....6. Genetic Testing in Documented or S...
.... In patients in whom a conduction disorder-caus...
...with inherited conduction disease, genet...
...ep Apnea Evaluation and Treatment in...
...with documented or suspected brady...
...with sleep-related bradycardia or co...
...who have previously received or are bein...
...sive Testing...
...3.1. Implantable Cardiac Monitor in Patient...
...ysiology Testing in Patients With Documented or S...
...ycardia Attributable to...
....3.1. Acute Management of Reversible Causes...
...re 4. Acute Bradycardia A...
...Potentially Reversible or Treatable C...
...1. Atropine and Beta Agonists for Bra...
...with SND associated with symptoms or...
...In patients with SND associated with sym...
...atients who have undergone heart transplant with...
...e 5. Acute Medical Management of Bradycardia Attr...
.... Therapy of Beta Blocker and Calcium Channel...
...In patients with bradycardia associa...
...ts with bradycardia associated with symp...
...n patients with bradycardia associ...
....3.2.3. Therapy of Digoxin Mediated Bradycardia At...
...s with bradycardia associated with symptoms or...
...with bradycardia associated with...
...Theophylline/Aminophylline for Bradycard...
...heart transplant patients, aminophylline or...
...with SND associated with symptoms or hemo...
....3. Temporary Pacing for Bradycardia Attri...
...In patients with persistent hemodynamically unst...
...ients with SND with severe symptoms or hemodynamic...
...ents with SND with minimal and/or inf...
Figure 5. Acute Pacing Al...
...nvasive Testi...
...1. General Principles of Chronic Therapy/Man...
...In asymptomatic individuals with sin...
...In patients with sleep-related sinus bra...
...ts with asymptomatic SND, or in those...
...sient/Reversible Causes (Including Medications...
.... Patients presenting with symptomatic SND secon...
...onal Testing of Bradycardia Attributable t...
...patients with symptoms suggestive of bradyc...
...c patients with suspected SND, EPS for the asse...
...ts with asymptomatic sinus bradycardia, an EPS sh...
...nt Pacing for Chronic Therapy/Management of Brad...
.... In patients with symptoms that are directly a...
.... In patients who develop symptomatic...
...tients with tachy-brady syndrome and symptoms attr...
...nts with symptomatic chronotropic incompetence, pe...
...patients with symptoms that are likely attr...
...rmanent Pacing for Chronic Therapy/Ma...
1. In symptomatic patients with SND, a...
...mptomatic patients with SND and intact atriovent...
...In symptomatic patients with SND who have...
...ic patients with SND in which frequent ventri...
...Chronic SND Management Algorithm...
...6. Etiology of Atrioventricular BlockHaving...
...ute Manageme...
...Acute Management of Reversible Causes o...
...Patients with transient or reversible causes...
...d patients with symptomatic second-de...
...with second-degree or third-degree atrio...
...patients with symptomatic second-deg...
...e Medical Therapy for Bradycardia Attrib...
...atients with second-degree or third-...
2. For patients with second-degree or third...
...with second-degree or third-degree a...
...porary Pacing for Bradycardia Attributable to Atr...
1. For patients with second-degree or third-degree...
...s who require prolonged temporary tr...
...patients with second-degree or third-d...
...agement of Bradycardia or Pauses Attrib...
....4.1. General Principles of Chronic...
...patients with first-degree atrioventricular...
...tomatic patients with first-degree atriove...
...tially Reversible or Transient Cause...
...s with symptomatic atrioventricular...
.... In patients who had acute atrioventricu...
...patients with asymptomatic vagally media...
...nal Testing for Chronic Therapy/Mana...
...In patients with symptoms (e.g., lightheadednes...
...with exertional symptoms (e.g., chest...
...d patients with second-degree atriov...
4. In selected patients with second-degree...
...manent Pacing for Chronic Therapy/Management of...
...with acquired second-degree Mobitz typ...
...ients with neuromuscular diseases associated...
.... In patients with permanent AF and symptom...
.... In patients who develop symptomatic a...
...ts with an infiltrative cardiomyopat...
...ts with lamin A/C gene mutations, including...
...ith marked first-degree or second-degree Mobitz...
8. In patients with neuromuscular diseases, su...
...nt Pacing Techniques and Methods for C...
...s with SND and atrioventricular block who re...
...lect patients with atrioventricula...
...or patients in sinus rhythm with a...
...In patients with atrioventricular block who...
...with atrioventricular block who have an indi...
...s with atrioventricular block at the level of th...
...nts with permanent or persistent AF in w...
...ders (With 1:1 Atrioventricular Conduction)...
...of Conduction Disorders (With 1:1 Atrioven...
...patients with newly detected LBBB, a...
...ymptomatic patients with conduction sys...
...ected patients presenting with intraventricula...
...ith symptoms suggestive of intermittent br...
...In selected patients with LBBB in whom structur...
...cted asymptomatic patients with extensive conduct...
...symptomatic patients with LBBB in whom ischemic...
.... Management of Conduction Disorders...
...ts with syncope and bundle branch block who are fo...
...with alternating bundle branch block,...
...patients with Kearns-Sayre syndrome and condu...
...with Anderson-Fabry disease and QRS prol...
5. In patients with heart failure, a mildly to mo...
...In asymptomatic patients with isolate...
...8. Evaluation of Conduction Disorder...
...agement of Conduction Disorders Algorithm...
...ial Populations...
...1. Patients at Risk for Bradycardia During N...
...ho are thought to be at high risk for the de...
...ith LBBB who require pulmonary artery...
...ng After Isolated Coronary Artery...
...who have new postoperative SND or atrioventri...
...nts undergoing isolated coronary artery bypass...
...patients undergoing coronary artery bypass surger...
....1.2.2. Pacing After Surgery for Atri...
...atients undergoing surgery for AF, routine pl...
...ients who have new postoperative SND or atriovent...
...atients undergoing surgery for AF wh...
.... Pacing After Aortic Valve Surgery...
...In patients undergoing surgical aortic valve repla...
...patients who have new postoperative...
...tients undergoing aortic valve surgery who...
...Pacing After Mitral Valve Surg...
...atients who have new postoperative S...
...patients undergoing mitral valve...
...nts undergoing surgical mitral valve rep...
...3.3. Pacing After Tricuspid Valve Sur...
...ndergoing tricuspid valve surgery, routi...
...s who have new postoperative SND or atr...
...n patients who are undergoing tricuspid valve r...
...Conduction Disturbances After Transcatheter...
...patients who have new atrioventricular block af...
...ts with new persistent bundle branch b...
...n patients with new persistent LBBB af...
...nts Undergoing Surgical Myectomy or Alcoho...
...tients with second-degree Mobitz ty...
...atients with hypertrophic cardiomyo...
...patients with hypertrophic cardiomyop...
...ients with hypertrophic cardiomyop...
...nagement of Bradycardia in Adults With Adult Conge...
...dults with adult congenital heart...
...ts with ACHD and symptomatic brady...
...dults with congenital complete atrioventricula...
...ith ACHD and postoperative second-deg...
...tic adults with congenital complete atri...
...with repaired ACHD who require permanent pacing f...
7. In adults with ACHD with preexisting s...
...ith ACHD and pacemakers, atrial-based permanent...
...ted adults with ACHD and venous to systemic intrac...
...t of Bradycardia in the Context of Ac...
...s presenting with an acute MI, temporary pacing...
...nts who present with SND or atrioven...
...ts presenting with an acute MI with second d...
...s with an acute MI with symptomatic or hemod...
...nts with an acute MI and transient atrioventric...
...patients with an acute MI and a new...
...ients With Epilepsy and Symptomatic Bradycard...
...atients with epilepsy associated with severe...
...Recommendations...
...Bradycardia and Conduction Tissue Disease...
...patients who require permanent pacing therapy,...
...Decision-Making for Pacemaker Implantation...
...with symptomatic bradycardia or cond...
...Patients considering implantation of a pac...
...patients with indications for permanent pacing bu...
...nuation of Pacemaker Therapy1. In pa...