From the Guidelines
When taking a history for acute bradycardia, it is crucial to focus on identifying the cause, severity, and associated symptoms to guide subsequent management decisions and improve patient outcomes. The history should begin by asking about the onset, duration, and any precipitating factors of the bradycardia, as well as inquiring about symptoms such as chest pain, shortness of breath, dizziness, syncope, or altered mental status, which may indicate hemodynamic compromise 1.
Key Components of the History
- Recent medication changes, particularly beta-blockers, calcium channel blockers, digoxin, or antiarrhythmics that can cause bradycardia
- Medical history for cardiac conditions like sick sinus syndrome, heart block, or prior myocardial infarction
- Systemic illnesses such as hypothyroidism, electrolyte abnormalities, or increased intracranial pressure
- History of cardiac procedures or pacemaker implantation
- Recent infections that could cause myocarditis
- Family history of cardiac disease or sudden death
Importance of a Thorough Medication Review
A thorough medication review is essential, including prescription drugs, over-the-counter medications, and supplements, as it can help identify potential causes of bradycardia and guide management decisions 1.
Guiding Subsequent Management Decisions
The comprehensive history helps determine whether the bradycardia is physiologic (as in trained athletes), pathologic but stable, or potentially life-threatening requiring immediate intervention, such as atropine, dopamine, or isoproterenol administration, as outlined in the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay 1. The goal of the history is to prioritize morbidity, mortality, and quality of life outcomes by guiding appropriate and timely interventions.
From the Research
History Taking in Acute Bradycardia
- The evaluation and management of bradycardia involve assessing symptoms, as pathology can occur within the sinus node, atrioventricular (AV) nodal tissue, and the specialized His-Purkinje conduction system 2
- Treatment should rarely be prescribed solely on the basis of a heart rate lower than an arbitrary cutoff or a pause above certain duration 2
- A critical component in the evaluation and management of bradycardia is the assessment of symptoms, as bradycardia can be observed as a normal phenomenon in young athletic individuals, and in patients as part of normal aging or disease 2
Management Strategies
- Transcutaneous cardiac pacing (TCP) is a rapid, time-saving, and noninvasive ventricular stimulation that is tolerated by conscious patients despite the painful intervention for treatment of symptomatic bradycardias 3
- TCP has been shown to be clinically effective in patients with atropine-resistant unstable bradycardia, with statistically significant differences in mean systolic and diastolic blood pressure and median heart rate before and after administration 3
- Various management strategies for symptomatic bradycardia, including observation, non-invasive management, early permanent pacemaker (PPM) implantation, and delayed PPM implantation, have been compared in terms of clinical outcomes 4
Clinical Outcomes
- Adverse events related to bradycardia, such as syncope, central line-associated bloodstream infections, cardiac arrest, and in-hospital mortality, were similar in patients who underwent early compared to delayed PPM implantation 4
- Temporary transvenous pacing was associated with higher adverse events, and weekend admissions were associated with increased temporary transvenous pacing, prolonged median time to PPM implantation, and prolonged median length of stay 4