How is symptomatic sinus bradycardia managed?

From the Guidelines

Symptomatic sinus bradycardia is managed through a combination of treating underlying causes, medication, and potentially pacemaker implantation, with the primary goal of improving cardiac output and tissue perfusion. The management of symptomatic sinus bradycardia involves several key steps, including:

• Addressing reversible causes such as medications (beta-blockers, calcium channel blockers), hypothyroidism, or electrolyte abnormalities, as recommended by the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay 1.
• For acute symptomatic bradycardia, administering atropine 0.5 mg IV, which can be repeated every 3-5 minutes up to a total dose of 3 mg, as outlined in the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay 1.
• If atropine is ineffective, considering temporary transcutaneous or transvenous pacing, as well as other pharmacologic options such as dopamine (2-10 mcg/kg/min IV) or epinephrine (2-10 mcg/min IV), as recommended by the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay 1.
• For chronic symptomatic bradycardia that cannot be managed by treating underlying causes or medication adjustments, permanent pacemaker implantation is the definitive treatment, particularly for patients who experience syncope, presyncope, confusion, fatigue, or exercise intolerance due to bradycardia, as indicated by the 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities 1 and the 2013 ESC guidelines on cardiac pacing and cardiac resynchronization therapy 1. Some key points to consider in the management of symptomatic sinus bradycardia include:
• The importance of identifying and addressing reversible causes of bradycardia, such as medications or underlying medical conditions, as recommended by the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay 1.
• The role of atropine and other pharmacologic agents in the acute management of symptomatic bradycardia, as outlined in the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay 1.
• The indications for permanent pacemaker implantation in patients with chronic symptomatic bradycardia, as indicated by the 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities 1 and the 2013 ESC guidelines on cardiac pacing and cardiac resynchronization therapy 1.

From the FDA Drug Label

OVERDOSAGE ... Treatment In the treatment of atropine poisoning, respiratory assistance and symptomatic support are indicated The FDA drug label does not answer the question.

From the Research

Management of Symptomatic Sinus Bradycardia

Symptomatic sinus bradycardia can be managed through various methods, including pharmacological therapy and pacing. The choice of treatment depends on the underlying cause and the patient's symptoms.

• Pharmacological Therapy:
  • Glucagon may be used to treat symptomatic bradycardia, particularly in the presence of beta-adrenergic blockade and calcium channel blockade 2.
  • Theophylline has emerged as a reasonable alternative strategy for the medical management of bradycardia in the elderly, with dosages between 400 and 600 mg/d administered in divided doses 3.
• Pacing:
  • The treatment of choice for chronic, symptomatic bradycardia is the placement of a cardiac pacemaker 3.
  • Patients with deficient chronotropic response to atropine administration may require preventive pacemaker implantations, as identified by isoproterenol tests 4.
• Monitoring:
  • Older patients with active cardiac conditions should have heart rate and blood pressure monitoring during infusion of pulse dose steroids, as they may develop symptomatic sinus bradycardia 5.
  • Patients with asymptomatic sinus bradycardia can be evaluated using the combined administration of atropine and isoproterenol to assess chronotropic reserve 4.
• Underlying Mechanisms:
  • Abnormal prolongation of sinus node recovery time is dependent upon the underlying mechanism of sinus node dysfunction, which can be intrinsic or due to disturbed autonomic regulation 6.