Bradycardia medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
Medical treatment of bradycardia is categorized into emergent and permanent. Usually, [[sinus bradycardia]] treatment is not recommended for [[asymptomatic]] patients. Correcting underlying [[electrolyte]] or acid-base deficiencies or [[hypoxia]] in symptomatic patients. Intravenous [[atropine]] can temporarily help symptomatic patients. | Medical treatment of [[bradycardia]] is categorized into emergent and permanent. Usually, [[sinus bradycardia]] treatment is not recommended for [[asymptomatic]] patients. Correcting underlying [[electrolyte]] or acid-base deficiencies or [[hypoxia]] in [[symptomatic]] patients. [[Intravenous]] [[atropine]] can temporarily help [[symptomatic]] patients. | ||
== 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society<ref name="pmid30586772">{{cite journal| author=Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR | display-authors=etal| title=2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. | journal=Circulation | year= 2019 | volume= 140 | issue= 8 | pages= e382-e482 | pmid=30586772 | doi=10.1161/CIR.0000000000000628 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30586772 }}</ref> == | |||
=== Recommendations for Atropine and Beta Agonists for Bradycardia Attributable to SND === | |||
{| class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | |||
|- | |||
| bgcolor="LemonChiffon" |'''1.'''In patients with SND associated with symptoms or hemodynamic compromise, atropine is reasonable to increase sinus rate.''(Level of Evidence: C-LD)'' | |||
|} | |||
{| class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | |||
|- | |||
| bgcolor="LemonChiffon" |'''1.'''In patients with SND associated with symptoms or hemodynamic compromise who are at low likelihood of coronary ischemia, isoproterenol, dopamine, dobutamine, or epinephrine may be considered to increase heart rate and improve symptoms. ''(Level of Evidence: C-LD)'' | |||
|} | |||
=== Recommendations for Therapy of Beta Blocker and Calcium Channel Blocker Mediated Bradycardia === | |||
{| class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | |||
|- | |||
| bgcolor="LemonChiffon" |'''1.'''In patients with bradycardia associated with symptoms or hemodynamic compromise because of calcium channel blocker overdose, intravenous calcium is reasonable to increase heart rate and improve symptoms. ''(Level of Evidence: C-LD)'' | |||
|- | |||
| bgcolor="LemonChiffon" |'''2.''' In patients with bradycardia associated with symptoms or hemodynamic compromise because of beta- blocker or calcium channel blocker overdose, glucagon is reasonable to increase heart rate and improve symptoms. ''(Level of Evidence: C-LD)'' | |||
|- | |||
| bgcolor="LemonChiffon" |'''3.''' In patients with bradycardia associated with symptoms or hemodynamic compromise because of beta- blocker or calcium channel blocker overdose, high-dose insulin therapy is reasonable to increase heart rate and improve symptoms. (''Level of Evidence: C-LD)'' | |||
|} | |||
=== Recommendations for Therapy of Digoxin Mediated Bradycardia Attributable to SND or Atrioventricular Block === | |||
{| class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | |||
|- | |||
| bgcolor="LemonChiffon" |'''1.'''In patients with bradycardia associated with symptoms or hemodynamic compromise in the setting of digoxin toxicity, digoxin Fab antibody fragment is reasonable to increase heart rate and improve symptoms. ''(Level of Evidence: C-LD)'' | |||
|} | |||
=== Recommendations for Theophylline/Aminophylline for Bradycardia Attributable to SND === | |||
{| class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | |||
|- | |||
| bgcolor="LemonChiffon" |'''1.'''In post-heart transplant patients, aminophylline or theophylline is reasonable to increase heart rate if clinically indicated. ''(Level of Evidence: C-LD)'' | |||
|- | |||
| bgcolor="LemonChiffon" |'''2.''' In patients with SND associated with symptoms or hemodynamic compromise in the setting of acute spinal cord injury, aminophylline or theophylline is reasonable to increase heart rate and improve symptoms. ''(Level of Evidence: C-LD)'' | |||
|} | |||
==Medical Therapy== | ==Medical Therapy== | ||
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*Drug treatment for [[bradycardia]] is typically not indicated for patients who are [[Asymptomatic|asymptomatic.]] | *Drug treatment for [[bradycardia]] is typically not indicated for patients who are [[Asymptomatic|asymptomatic.]] | ||
*In symptomatic patients, underlying [[electrolyte]] or [[acid-base disorders]] or [[hypoxia]] should be corrected first. | *In symptomatic patients, underlying [[electrolyte]] or [[acid-base disorders]] or [[hypoxia]] should be corrected first. | ||
*IV [[atropine]] may provide temporary improvement in symptomatic patients, although its use should be balanced by an appreciation of the increase in myocardial oxygen demand this agent causes. [[Atropine]] 0.5-1 mg IV or ET q3-5min up to 3 mg total (0.04 mg/kg)<ref name="pmid20956224">{{cite journal |vauthors=Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, Sinz E, Morrison LJ |title=Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care |journal=Circulation |volume=122 |issue=18 Suppl 3 |pages=S729–67 |date=November 2010 |pmid=20956224 |doi=10.1161/CIRCULATIONAHA.110.970988 |url=}}</ref><ref name="pmid30412709">{{cite journal |vauthors=Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD |title=2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society |journal=J. Am. Coll. Cardiol. |volume=74 |issue=7 |pages=e51–e156 |date=August 2019 |pmid=30412709 |doi=10.1016/j.jacc.2018.10.044 |url=}}</ref> | *IV [[atropine]] may provide temporary improvement in symptomatic patients, although its use should be balanced by an appreciation of the increase in [[myocardial]] oxygen demand this agent causes. | ||
**Preferred regimen (1): [[Atropine]] 0.5-1 mg IV or ET q3-5min up to 3 mg total (0.04 mg/kg)<ref name="pmid20956224">{{cite journal |vauthors=Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, Sinz E, Morrison LJ |title=Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care |journal=Circulation |volume=122 |issue=18 Suppl 3 |pages=S729–67 |date=November 2010 |pmid=20956224 |doi=10.1161/CIRCULATIONAHA.110.970988 |url=}}</ref><ref name="pmid30412709">{{cite journal |vauthors=Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD |title=2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society |journal=J. Am. Coll. Cardiol. |volume=74 |issue=7 |pages=e51–e156 |date=August 2019 |pmid=30412709 |doi=10.1016/j.jacc.2018.10.044 |url=}}</ref> | |||
===Chronic Management=== | ===Chronic Management=== | ||
There are two main reasons for treating bradycardia: | There are two main reasons for treating [[bradycardia]]: | ||
#With bradycardia, the first is to address the associated symptoms, such as [[Fatigue (physical)|fatigue]], limitations on how much an individual can physically exert, [[fainting]] (syncope), [[dizziness]] or [[lightheadedness]], or other vague and non-specific symptoms. | #With [[bradycardia]], the first is to address the associated symptoms, such as [[Fatigue (physical)|fatigue]], limitations on how much an individual can physically exert, [[fainting]] (syncope), [[dizziness]] or [[lightheadedness]], or other vague and non-specific symptoms. | ||
#The other reason to treat bradycardia is if the person's ultimate outcome (prognosis) will be changed or impacted by the bradycardia. | #The other reason to treat [[bradycardia]] is if the person's ultimate outcome ([[prognosis]]) will be changed or impacted by the [[bradycardia]]. | ||
Treatment in this vein depends on whether any symptoms are present, and what the underlying cause is. | Treatment in this vein depends on whether any symptoms are present, and what the underlying cause is. Primary or [[idiopathic]] [[bradycardia]] is treated symptomatically if it is significant, and the underlying cause is treated if the [[bradycardia]] is secondary. | ||
Primary or [[idiopathic]] bradycardia is treated symptomatically if it is significant, and the underlying cause is treated if the bradycardia is secondary. | |||
{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=PE diagnosis Algorithm.}} | ||
Latest revision as of 01:58, 28 December 2022
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Bradycardia Microchapters |
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Bradycardia medical therapy On the Web |
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Risk calculators and risk factors for Bradycardia medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: M.Umer Tariq [2] Ibtisam Ashraf, M.B.B.S.[3]
Overview
Medical treatment of bradycardia is categorized into emergent and permanent. Usually, sinus bradycardia treatment is not recommended for asymptomatic patients. Correcting underlying electrolyte or acid-base deficiencies or hypoxia in symptomatic patients. Intravenous atropine can temporarily help symptomatic patients.
2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society[1]
Recommendations for Atropine and Beta Agonists for Bradycardia Attributable to SND
| Class IIa |
| 1.In patients with SND associated with symptoms or hemodynamic compromise, atropine is reasonable to increase sinus rate.(Level of Evidence: C-LD) |
| Class IIb |
| 1.In patients with SND associated with symptoms or hemodynamic compromise who are at low likelihood of coronary ischemia, isoproterenol, dopamine, dobutamine, or epinephrine may be considered to increase heart rate and improve symptoms. (Level of Evidence: C-LD) |
Recommendations for Therapy of Beta Blocker and Calcium Channel Blocker Mediated Bradycardia
| Class IIa |
| 1.In patients with bradycardia associated with symptoms or hemodynamic compromise because of calcium channel blocker overdose, intravenous calcium is reasonable to increase heart rate and improve symptoms. (Level of Evidence: C-LD) |
| 2. In patients with bradycardia associated with symptoms or hemodynamic compromise because of beta- blocker or calcium channel blocker overdose, glucagon is reasonable to increase heart rate and improve symptoms. (Level of Evidence: C-LD) |
| 3. In patients with bradycardia associated with symptoms or hemodynamic compromise because of beta- blocker or calcium channel blocker overdose, high-dose insulin therapy is reasonable to increase heart rate and improve symptoms. (Level of Evidence: C-LD) |
Recommendations for Therapy of Digoxin Mediated Bradycardia Attributable to SND or Atrioventricular Block
| Class IIa |
| 1.In patients with bradycardia associated with symptoms or hemodynamic compromise in the setting of digoxin toxicity, digoxin Fab antibody fragment is reasonable to increase heart rate and improve symptoms. (Level of Evidence: C-LD) |
Recommendations for Theophylline/Aminophylline for Bradycardia Attributable to SND
| Class IIa |
| 1.In post-heart transplant patients, aminophylline or theophylline is reasonable to increase heart rate if clinically indicated. (Level of Evidence: C-LD) |
| 2. In patients with SND associated with symptoms or hemodynamic compromise in the setting of acute spinal cord injury, aminophylline or theophylline is reasonable to increase heart rate and improve symptoms. (Level of Evidence: C-LD) |
Medical Therapy
Urgent Treatment
- Check drug list and remove drugs predisposing to bradycardia like beta blockers, calcium channel blocker, anti-arrhythmic drug.
- Drug treatment for bradycardia is typically not indicated for patients who are asymptomatic.
- In symptomatic patients, underlying electrolyte or acid-base disorders or hypoxia should be corrected first.
- IV atropine may provide temporary improvement in symptomatic patients, although its use should be balanced by an appreciation of the increase in myocardial oxygen demand this agent causes.
Chronic Management
There are two main reasons for treating bradycardia:
- With bradycardia, the first is to address the associated symptoms, such as fatigue, limitations on how much an individual can physically exert, fainting (syncope), dizziness or lightheadedness, or other vague and non-specific symptoms.
- The other reason to treat bradycardia is if the person's ultimate outcome (prognosis) will be changed or impacted by the bradycardia.
Treatment in this vein depends on whether any symptoms are present, and what the underlying cause is. Primary or idiopathic bradycardia is treated symptomatically if it is significant, and the underlying cause is treated if the bradycardia is secondary.
| Symptoms | |||||||||||||||||||||||||||||||||||||||
| Yes→ Hemodynamically Stable | Uncertain/no→ No immediate treatment Consider additional diagnostic testing: Ambulatory ECG ETT TSH | ||||||||||||||||||||||||||||||||||||||
| No→ IV atropine 0.5mg IV push; Can be repeated every three to five minutes upto 3mg total | Yes→ Signs/Symptoms of acute MI | ||||||||||||||||||||||||||||||||||||||
| Do HR and symptoms improve? | Yes→ Treat Accordingly | No→ Check for other causes (TSH, infection) | |||||||||||||||||||||||||||||||||||||
| No→ Temporary Pacemaker | Yes→ Monitor | ||||||||||||||||||||||||||||||||||||||
Contraindicated medications
Persistently severe bradycardia is considered an absolute contraindication to the use of the following medications:
Symptomatic bradycardia (except in patients with a functioning artificial pacemaker) is considered an absolute contraindication to the use of the following medications:
References
- ↑ Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR; et al. (2019). "2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society". Circulation. 140 (8): e382–e482. doi:10.1161/CIR.0000000000000628. PMID 30586772.
- ↑ Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, Sinz E, Morrison LJ (November 2010). "Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation. 122 (18 Suppl 3): S729–67. doi:10.1161/CIRCULATIONAHA.110.970988. PMID 20956224.
- ↑ Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD (August 2019). "2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society". J. Am. Coll. Cardiol. 74 (7): e51–e156. doi:10.1016/j.jacc.2018.10.044. PMID 30412709.