How to manage an elderly female patient with bradycardia and dizziness?

Management of Elderly Female with Bradycardia and Dizziness

In this elderly female with dizziness and heart rates of 53-60 bpm, you must first determine if the bradycardia is causing her symptoms through correlation of rhythm with symptoms, exclude reversible causes (especially medications and electrolyte abnormalities), and assess for hemodynamic instability before considering any intervention. 1, 2

Immediate Assessment Priorities

Determine if Bradycardia is Symptomatic

• Heart rates of 53-60 bpm alone do NOT require treatment if asymptomatic - this range can be physiologic in elderly patients, during sleep, or with increased parasympathetic tone 2
• Dizziness must be directly correlated with bradycardia episodes to justify intervention - symptoms may be multifactorial in elderly patients 1
• Document whether dizziness occurs specifically during bradycardic episodes using ambulatory monitoring if symptoms are intermittent 1, 2

Assess for Hemodynamic Compromise

Intervention is ONLY indicated if bradycardia causes: 2

• Hypotension (systolic BP <90 mmHg)
• Altered mental status or confusion
• Ischemic chest pain or angina
• Signs of acute heart failure (dyspnea, pulmonary edema)
• Syncope or presyncope with documented bradycardia

If none of these features are present, observation without treatment is appropriate even with heart rates in the 50s. 2

Exclude Reversible Causes First

Medication Review (Critical First Step)

Before any intervention, thoroughly review: 1

• Beta-blockers - most common culprit causing bradycardia and dizziness 3
• Calcium channel blockers (diltiazem, verapamil) - can cause bradycardia and AV block 3
• Digoxin, antiarrhythmics, or other negative chronotropic agents 1
• If medications are the cause and can be discontinued or dose-reduced, do this FIRST rather than proceeding to pacing 1

Laboratory Evaluation

Obtain immediately: 3

• Electrolytes (potassium, sodium) - hyperkalemia can cause severe bradycardia
• Renal function (creatinine, BUN) - acute kidney injury can precipitate BRASH syndrome (Bradycardia, Renal failure, AV blockade, Shock, Hyperkalemia) 4
• Thyroid function (TSH) - hypothyroidism is a reversible cause 1
• Complete blood count - anemia can cause dizziness independent of bradycardia

ECG Analysis Required

Obtain 12-lead ECG to determine: 1, 2

• Type of bradycardia: sinus bradycardia vs. AV block vs. junctional rhythm
• Presence of AV block: First-degree (benign), Mobitz II or third-degree (requires pacing regardless of symptoms) 1
• Evidence of structural heart disease (Q waves, left ventricular hypertrophy)

Management Algorithm Based on Findings

If Hemodynamically UNSTABLE (hypotension, altered mental status, chest pain):

1. Atropine 0.5 mg IV every 3-5 minutes (maximum 3 mg total) - first-line therapy 2, 5
   • Most effective for sinus bradycardia and AV nodal blocks
   • Less effective for infranodal blocks with wide-complex escape rhythms
2. Transcutaneous pacing if unresponsive to atropine - bridge to transvenous pacing 2
3. Consider vasopressor support if shock develops 4
4. If hyperkalemia and renal failure present (BRASH syndrome): urgent hemodialysis, stop all AV nodal blockers, aggressive multi-modal therapy 4

If Hemodynamically STABLE but Symptomatic:

For Medication-Induced Bradycardia:

• Gradually reduce or discontinue offending agent over 1-2 weeks 1, 3
• Switch to alternative agents without negative chronotropic effects (e.g., ACE inhibitors or ARBs for hypertension instead of beta-blockers) 1
• Monitor for symptom resolution before considering pacing

For Persistent Symptomatic Bradycardia After Reversible Causes Excluded:

• Ambulatory ECG monitoring (24-72 hour Holter or 30-day event monitor) to correlate symptoms with rhythm 1, 2
• If correlation confirmed between dizziness and bradycardia: permanent pacemaker is indicated 2, 5
• High-grade AV block (Mobitz II or third-degree) requires permanent pacing regardless of symptoms 1

If Asymptomatic or Symptoms NOT Correlated with Bradycardia:

• No intervention required - observation only 1, 2
• Reassess if symptoms worsen or new symptoms develop
• Patient education about when to seek care (syncope, severe dizziness, chest pain)

Special Considerations in Elderly Patients

Orthostatic Hypotension Assessment

• Perform lying-to-standing blood pressure measurements - orthostatic hypotension may be the primary cause of dizziness rather than bradycardia 3
• If orthostatic hypotension confirmed: non-pharmacologic measures (compression stockings, increased fluid/salt intake), review and reduce offending medications, consider fludrocortisone or midodrine 3, 6

Goals of Care Discussion

• Assess functional status, life expectancy, and quality of life priorities before device implantation 2
• Age alone is NOT a contraindication to pacing, but frailty and comorbidities must be considered 2
• Permanent pacemaker implantation carries procedural risks and long-term management implications 1

Critical Pitfalls to Avoid

1. Do NOT pace asymptomatic bradycardia - even heart rates in the 40s can be physiologic 2
2. Do NOT assume dizziness is from bradycardia - must document temporal correlation 1
3. Do NOT implant pacemaker before excluding reversible causes - medication adjustment may resolve symptoms 1
4. Do NOT miss BRASH syndrome - check renal function and potassium in all elderly patients with bradycardia and hypotension 4
5. Do NOT use atropine doses <0.5 mg - paradoxically may slow heart rate further 2