From the Guidelines
For new onset asymptomatic bradycardia with a heart rate of 58 beats per minute, the best initial approach is a thorough history and physical examination, focusing on medication review, symptoms assessment, and cardiovascular examination, as recommended by the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay 1.
Key Considerations
- Order an ECG to determine the type of bradycardia (sinus bradycardia, heart block, etc.) and basic laboratory tests including electrolytes, thyroid function, and complete blood count.
- Consider 24-hour Holter monitoring to detect intermittent bradycardia or pauses, especially if the patient has a history of syncope or presyncope.
- If the patient remains asymptomatic with no concerning ECG findings, observation without specific treatment is appropriate, as a heart rate of 58 is only mildly bradycardic and often normal in physically fit individuals or during sleep 1.
Medication Review
- For patients on medications that can cause bradycardia (beta-blockers, calcium channel blockers, digoxin), consider dose adjustment or medication change in consultation with the prescribing physician, as these medications can exacerbate bradycardia 1.
Further Evaluation
- Further cardiac evaluation with echocardiography or exercise stress testing may be warranted if there are concerns about structural heart disease or if symptoms develop, as recommended by the 2018 ACC/AHA/HRS guideline 1.
Patient Education
- Patients should be educated to report symptoms like dizziness, fatigue, syncope, or exercise intolerance that might indicate the bradycardia is becoming clinically significant, and to seek medical attention if these symptoms occur 1.
From the Research
Assessment of New Onset Bradycardia
- The patient's heart rate is 58 beats per minute, which is considered bradycardia 2.
- The patient is asymptomatic, which is a common presentation of bradycardia, especially in trained athletes or during sleep 2.
Evaluation of Bradycardia
- A thorough history and physical examination should be performed to determine the underlying cause of the bradycardia 3.
- The evaluation should include possible causes of sinoatrial node dysfunction or AV block 3.
- Electrocardiographic findings can help identify the type of bradydysrhythmia and guide management 4.
Management of Asymptomatic Bradycardia
- Asymptomatic bradycardia may not require treatment, but it is essential to monitor the patient's condition and adjust management as needed 3, 2.
- If the patient becomes symptomatic, treatment with atropine or pacing may be necessary 4, 2, 5, 6.
- The decision to treat asymptomatic bradycardia should be based on the severity of the bradycardia, the underlying cause, and the presence of adverse signs or risk of progression to asystole 3.