What is the plan for a patient with symptomatic bradycardia (abnormally slow heart rate) and a history of syncope, presenting with dizziness, requiring an onsite provider visit with neurologic assessment and electrocardiogram (EKG) review?

From the Guidelines

The patient should be scheduled for an immediate onsite provider visit for a comprehensive evaluation of their symptomatic bradycardia, dizziness, and concerning history of multiple syncopal episodes. This recommendation is based on the 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1. The provider should perform a thorough neurological assessment, review the EKG findings, and evaluate the patient's current medications that might contribute to bradycardia.

Some key considerations for the onsite provider visit include:

• Performing orthostatic vital signs to assess for orthostatic hypotension
• Carotid sinus massage if appropriate, to assess for carotid sinus hypersensitivity
• Consideration for additional cardiac monitoring such as a 24-hour Holter monitor or event recorder
• Evaluation for potential pacemaker placement, given the patient's report of approximately one hundred syncopal episodes, which may indicate a serious cardiac conduction disorder 1.

Given the potential risks associated with symptomatic bradycardia, including injury from falls and life-threatening complications, urgent cardiology consultation is warranted. In the interim, the patient should be advised to avoid situations that might trigger symptoms and to rise slowly from sitting or lying positions. The patient should also be instructed to keep a symptom diary correlating episodes of dizziness with activities, meals, and medications. This comprehensive approach is necessary to ensure the patient's safety and to determine the underlying cause of their symptoms.

From the FDA Drug Label

Atropine-induced parasympathetic 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.

The patient's history of symptomatic bradycardia and syncope suggests that they may benefit from treatment with atropine to prevent further episodes of bradycardia.

• Atropine can abolish reflex vagal cardiac slowing or asystole, and prevent or abolish bradycardia or asystole produced by various factors.
• Given the patient's history, an onsite provider visit with a neuro assessment is necessary to evaluate the patient's condition and determine the best course of treatment.
• The patient's dizziness and history of syncope also require careful evaluation and management to prevent further episodes 2.

From the Research

Symptomatic Bradycardia and Dizziness

• The patient's symptoms of dizziness and history of bradycardia, including reported past episodes of syncope, require careful evaluation and management 3.
• Bradycardia can be caused by various factors, including sinus, atrial, or junctional bradycardia, or problems with the conduction system, such as an atrioventricular block 3.
• The patient's history of syncope, which has occurred "probably one hundred times" per patient report, suggests a potential link between bradycardia and symptoms 3.

Evaluation and Management

• The evaluation of symptomatic bradycardia should focus on determining the underlying cause of the patient's symptoms and assessing the need for treatment 4.
• Treatment options for symptomatic bradycardia include atropine, percutaneous pacing, and placement of a permanent pacemaker 3, 5.
• The choice of treatment depends on the underlying cause of bradycardia, the severity of symptoms, and the presence of any reversible causes, such as medication toxicity or hyperkalemia 6.

Pacemaker Implantation

• Permanent pacemaker implantation is a common treatment for symptomatic bradycardia, particularly in patients with sick sinus syndrome or high-degree atrioventricular block 3, 6.
• However, pacemaker implantation is not without risks, including infection, technical problems, and morbidity such as scar formation 5.
• Alternative treatment options, such as atropine, may be effective in managing symptoms and avoiding the need for pacemaker implantation in certain cases 5.

On-Site Provider Visit and Neuro Assessment

• Given the patient's history of dizziness and syncope, an on-site provider visit with a neuro assessment is necessary to evaluate the patient's symptoms and determine the underlying cause of bradycardia 3, 7.
• The provider should review the patient's EKG and medical history to assess the need for further evaluation or treatment 3, 4.