Should a patient with bradycardia (abnormally slow heart rate) and syncope (fainting) have a cardiology consult prior to surgery?

Cardiology Consultation for Patients with Bradycardia and Syncope Prior to Surgery

Patients with bradycardia and syncope should have a cardiology consultation prior to surgery due to the increased risk of perioperative cardiac complications and the need for specialized management of conduction disorders. 1

Rationale for Cardiology Consultation

Bradycardia with syncope represents a significant cardiac conduction disorder that requires thorough evaluation before subjecting a patient to the hemodynamic stresses of surgery. The 2018 ACC/AHA/HRS Bradycardia Guidelines provide clear direction on managing these patients:

• Syncope with bradycardia indicates possible serious conduction system disease that may require permanent pacing before elective procedures 1
• Patients with bundle branch block and syncope who have HV interval ≥70 ms or evidence of infranodal block have a Class I recommendation for permanent pacing 1
• The combination of syncope and bradycardia significantly increases the likelihood of a cardiac cause requiring intervention 2

Pre-Surgical Management Algorithm

1. Initial Assessment:

   • Determine if bradycardia is symptomatic (syncope confirms this)
   • Evaluate the severity and type of conduction disorder (sinus node dysfunction vs. AV block)
   • Review ECG for bundle branch blocks, PR prolongation, or other conduction abnormalities 3

2. Cardiology Consultation:

   • The cardiologist should perform comprehensive evaluation including:
     • Review of bradycardia characteristics (resting vs. episodic)
     • Assessment of structural heart disease
     • Evaluation for reversible causes
     • Determination of need for permanent pacing before surgery 1

3. Risk Stratification:

   • High-risk features requiring definitive management before elective surgery:
     • Alternating bundle branch block (Class I indication for permanent pacing)
     • Syncope with documented bradycardia/asystole
     • Evidence of infranodal block on electrophysiology studies 1

Perioperative Management

• For patients with confirmed high-risk bradycardia:

  • Permanent pacemaker implantation should be considered before elective surgery 1
  • Allow adequate time between pacemaker implantation and surgery (typically 1-2 weeks)

• For patients undergoing urgent/emergent surgery:

  • Placement of transcutaneous pacing pads is reasonable (Class IIa recommendation) 1
  • Availability of temporary transvenous pacing capability in the operating room

Common Pitfalls to Avoid

1. Underestimating risk: Bradycardia with syncope represents a potentially life-threatening condition that can worsen during anesthesia and surgery due to autonomic effects and medications

2. Inadequate preoperative evaluation: Simply documenting bradycardia without determining its mechanism and hemodynamic significance can lead to unexpected intraoperative complications

3. Delaying necessary pacing: The guidelines clearly state that patients with symptomatic bradycardia (which includes syncope) should receive appropriate intervention before elective procedures 1

4. Overreliance on temporary measures: While transcutaneous pacing pads are reasonable for emergency situations, they should not replace appropriate preoperative evaluation and management of significant conduction disorders

Bradycardia with syncope represents a clear indication for cardiology consultation prior to surgery to ensure optimal patient outcomes and reduce perioperative morbidity and mortality.