Do you hold if heart rate is less than 60 beats per minute (bpm)?

Management of Bradycardia (Heart Rate Less Than 60 BPM)

For adults, do not hold medications when heart rate is less than 60 beats per minute (bpm) unless there are signs of poor perfusion or the patient is hemodynamically unstable. 1

Adult Bradycardia Management

• The American College of Cardiology/American Heart Association/Heart Rhythm Society guidelines define bradycardia as a heart rate <60 bpm in adults, though population studies often use a lower cutoff of 50 bpm 1
• For adults on beta-blockers, titrated rate control should maintain a heart rate of 60 to 80 bpm in the absence of hypotension, as this regimen has demonstrated efficacy 1
• Heart rates between 50-60 bpm in adults are often well-tolerated and may not require intervention, particularly in physically fit individuals 1
• The presence of bradycardia alone should not be used for clinical decision-making; multiple factors should be taken into consideration for the individual patient 1

When to Intervene for Bradycardia

• Intervention is warranted when bradycardia is accompanied by:

  • Hypotension
  • Signs of poor perfusion (pallor, mottling, cyanosis)
  • Altered mental status
  • Chest pain
  • Shortness of breath 1

• In hospitalized heart failure patients with atrial fibrillation, heart rates <60 bpm at discharge have been associated with better clinical outcomes compared to rates >81 bpm 2

Pediatric Considerations

• For infants and children, a heart rate <60 bpm with signs of poor perfusion despite support of oxygenation and ventilation is an indication for chest compressions 1
• In pediatric patients, cardiac output largely depends on heart rate, so profound bradycardia with poor perfusion requires immediate intervention as cardiac arrest is imminent 1
• For neonates, normal heart rate ranges are higher (91-166 bpm in the first week of life), and intervention thresholds differ from those for adults 3

Perioperative Beta-Blocker Management

• For patients on beta-blockers undergoing surgery, continue beta-blocker therapy perioperatively 1
• When using beta-blockers perioperatively, titrate to maintain heart rate between 60-80 bpm in the absence of hypotension 1
• Routine administration of high-dose beta-blockers without dose titration for patients undergoing noncardiac surgery is not recommended and may be harmful 1

Monitoring Considerations

• When monitoring heart rate, take up to 10 seconds to accurately assess pulse 1
• Real-time monitoring systems often set alerts for heart rates below 60 bpm to notify healthcare providers of potential bradycardia 4
• Heart rate variability decreases with age, with parasympathetic function declining faster than sympathetic function 5

Common Pitfalls to Avoid

• Avoid withholding necessary medications solely based on heart rate without considering clinical context and patient symptoms 1
• Don't confuse asymptomatic bradycardia with clinically significant bradycardia requiring intervention 1
• For patients on beta-blockers, avoid abrupt discontinuation which can lead to rebound tachycardia and increased risk of adverse cardiac events 1
• Remember that heart rate requirements differ significantly between pediatric and adult populations - a heart rate of 55 bpm may be normal for an adult but critically low for a child 3