How to manage bradycardia (heart rate of 36) in an 85-year-old athlete?

From the Guidelines

The management of bradycardia in an 85-year-old athlete with a heart rate of 36 should prioritize distinguishing between physiological adaptation and pathological condition, with asymptomatic cases potentially requiring only observation as athletic conditioning can lead to lower resting heart rates 1. To approach this case, it's crucial to first assess if the patient is symptomatic, experiencing symptoms such as dizziness, fatigue, confusion, or syncope, as this guides the urgency of intervention.

• For asymptomatic bradycardia in athletes, observation may be appropriate, given that athletic conditioning often results in lower resting heart rates, as noted in the context of endurance sports and high levels of fitness 1.
• If the patient is symptomatic, immediate medical evaluation is necessary to determine the cause of the bradycardia and to guide treatment. Treatment options for symptomatic bradycardia include temporary measures such as atropine 0.5mg IV, which may be repeated up to a maximum of 3mg for acute symptomatic bradycardia 1.
• Permanent pacemaker implantation may be considered if the bradycardia is due to sinus node dysfunction or AV block.
• A thorough medication review is essential, as certain medications like beta-blockers, calcium channel blockers, and antiarrhythmics can exacerbate bradycardia.
• Correcting any electrolyte imbalances is also crucial in the management of bradycardia. For this elderly athlete, a comprehensive cardiac evaluation including ECG, echocardiogram, and possibly Holter monitoring is recommended to differentiate between athletic bradycardia, which may not require intervention, and age-related conduction system disease that necessitates treatment 1.
• The decision for pacemaker implantation should consider the patient's activity level, symptoms, and underlying cardiac function, weighing the benefits of improved heart rate against the risks associated with the procedure.

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.

Management of Bradycardia: Atropine can be used to manage bradycardia (heart rate of 36) in an 85-year-old athlete.

• Key Consideration: The patient's age (>65 years old) may affect the pharmacokinetics of atropine, with a potentially longer elimination half-life.
• Dosage: The dosage of atropine is not specified in the provided text, but it is essential to follow the recommended dosage guidelines for the patient's age and condition.
• Administration: Atropine can be administered intravenously, and its effects on heart rate can be expected to occur within a certain time frame, considering the pharmacokinetics of the drug.
• Monitoring: Close monitoring of the patient's heart rate, blood pressure, and other vital signs is crucial during atropine administration. 2

From the Research

Management of Bradycardia in an 85-year-old Athlete

• The treatment of bradycardia (heart rate of 36) in an 85-year-old athlete requires careful consideration of the underlying cause and the patient's overall health status 3, 4, 5, 6.
• In general, bradycardia can be managed with atropine, but this may not always be effective and can even worsen the condition in some cases, particularly in patients with atrioventricular blocks at the level of the His-Purkinje fibers (infranodal) 3.
• Alternative treatments, such as aminophylline, may be considered in cases where atropine is ineffective or contraindicated 4.
• The use of beta-blocking agents and sodium channel blockers should be avoided in patients with bradycardia, as these medications can exacerbate the condition 5.
• In patients with acute myocardial infarction and sinus bradycardia, atropine may be effective in improving heart rate and reducing symptoms, but careful monitoring is necessary to avoid adverse effects 6.

Considerations for Athletes

• Endurance training can affect maximum heart rate, and athletes may experience a decrease in maximum heart rate with regular aerobic exercise 7.
• Tapering or detraining can increase maximum heart rate, and monitoring heart rate can help prevent overtraining 7.
• The management of bradycardia in athletes should take into account their individual training status and overall health, and may require collaboration with a sports medicine specialist 7.

Key Points

• Bradycardia in an 85-year-old athlete requires careful evaluation and management.
• Atropine may be effective in some cases, but alternative treatments should be considered if it is ineffective or contraindicated.
• Avoidance of beta-blocking agents and sodium channel blockers is recommended.
• Monitoring heart rate and adjusting training intensity can help prevent overtraining and improve athletic performance.