From the Guidelines
Asymptomatic junctional bradycardia typically does not require treatment. According to the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay 1, patients with sinus node dysfunction (SND) are typically stable and minimally symptomatic on presentation, and no acute therapy is usually required.
Key Considerations
- Evaluation of SND and assessment for potentially reversible causes can be performed in an outpatient setting 1.
- Treatment may not be necessary in some cases, such as stopping a beta blocker in an asymptomatic patient with sinus bradycardia after ST-elevation MI 1.
- Some patients with tachy-brady syndrome may have improvement of sinoatrial node function after treatment aimed at maintaining sinus rhythm 1.
Approach to Management
- Observation is the recommended approach for patients who are hemodynamically stable and not experiencing symptoms such as dizziness, syncope, fatigue, or exercise intolerance.
- If the patient develops symptoms or if the bradycardia is severe, intervention may be necessary, and the decision to intervene is based on the severity of symptoms, the degree of bradycardia, and underlying causes.
- Addressing underlying causes, such as enhanced vagal tone, medications (beta-blockers, calcium channel blockers), or sinus node dysfunction, is important before considering more invasive interventions.
From the FDA Drug Label
Atropine Sulfate Injection, USP, is indicated for temporary blockade of severe or life threatening muscarinic effects, e.g., as an antisialagogue, an antivagal agent, an antidote for organophosphorus or muscarinic mushroom poisoning, and to treat bradyasystolic cardiac arrest. Atropine-induced parasympatholic inhibition may be preceded by a transient phase of stimulation, especially on the heart where small doses first slow the rate before characteristic tachycardia develops due to paralysis of vagal control Adequate doses of atropine abolish various types of reflex vagal cardiac slowing or asystole The drug also prevents or abolishes bradycardia or asystole produced by injection of choline esters, anticholinesterase agents or other parasympathomimetic drugs, and cardiac arrest produced by stimulation of the vagus.
Treatment for asymptomatic junctional bradycardia may include atropine, as it can prevent or abolish bradycardia or asystole produced by vagal stimulation.
- Key points:
From the Research
Junctional Bradycardia
- Junctional bradycardia is a type of bradycardia that can be asymptomatic or symptomatic 3, 4.
- Asymptomatic bradycardia is common, especially among trained athletes or during sleep, and does not necessitate further treatment 3, 4.
- Symptomatic patients with junctional bradycardia may experience symptoms such as syncope, dizziness, chest pain, dyspnea, or fatigue 3.
Treatment of Asymptomatic Junctional Bradycardia
- Asymptomatic junctional bradycardia does not require treatment, as it is considered to have a benign course 4.
- However, evaluation and risk stratification of individuals presenting with asymptomatic bradycardia is important to prevent implantation of unnecessary permanent pacing devices and to reduce significant morbidity 4.
Treatment of Symptomatic Junctional Bradycardia
- Symptomatic patients with junctional bradycardia should be treated with atropine in the acute setting 3, 5.
- Percutaneous pacing can be used as a bridge to definitive treatment, and the only therapy for persistent bradycardia is placement of a permanent pacemaker 3.
- Patients with symptomatic bradycardia, including those with junctional bradycardia, should be evaluated and managed according to the 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients with Bradycardia and Cardiac Conduction Delay 6.