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exercise intolerance shortness of breath cannon a-waves in jugular venous pulse jugular venous distension
Diagnostic tests
1st tests to order
12-lead ECG Holter monitoring event monitor exercise testing carotid sinus massage echocardiogram thyroid function tests basic metabolic panel cardiac markers serum digoxin level serum creatinine
Tests to consider
implantable-loop recorder tilt-table testing electrophysiology testing Diagnostic tests details
Treatment details
Acute
haemodynamically unstable pharmacotherapy temporary pacing haemodynamically stable: sinus node dysfunction o o o o o reversible cause: asymptomatic or mild symptoms treatment of underlying cause theophylline reversible cause: severe symptoms treatment of underlying cause + temporary pacing irreversible cause: asymptomatic or mild symptoms reassurance irreversible cause: severe symptoms permanent pacing haemodynamically stable: acquired AV block o o o o reversible cause: asymptomatic without indications for pacing treatment of underlying cause reversible cause: symptomatic or indications for pacing treatment of underlying cause + temporary pacing irreversible cause: asymptomatic without indications for pacing reassurance irreversible cause: symptomatic or indications for pacing permanent pacing hemodynamically stable: congenital AV block o o asymptomatic without indications for pacing reassurance symptomatic or indications for pacing permanent pacing haemodynamically stable: vagally mediated bradycardia o o carotid hypersensitivity syndrome permanent pacing neurocardiogenic or vasovagal syncope lifestyle modifications
o o
Summary
Any heart rhythm slower than 50 bpm, even if transient, owing to sinus node dysfunction and/or atrioventricular (AV) conduction abnormalities. Causes include intrinsic sinus node and AV nodal disease, or extrinsic influences, which may be reversible. Common symptoms include syncope, fatigue, and dizziness; however, the patient may be asymptomatic. Evaluation involves determining the association of symptoms with heart rate and an assessment of underlying cardiovascular conditions. ECG is the diagnostic test of choice. Patients with a reversible cause may not require long-term therapy; however, patients with nonreversible causes may require an implantable pacemaker with or without a defibrillator. Urgent treatment may include temporary pacing and drug interventions. Potentially life-threatening complications, including cardiovascular collapse and death, may occur.
Definition
While some consider bradycardia to be a heart rate <60 bpm, this is in dispute and most consider rates of <50 bpm to represent bradycardia. A study of 500 normal people using ECG recordings showed the mean afternoon heart rate to be 70 bpm in men and women, with two standard deviations being 46 to 93 bpm in men and 51 to 95 bpm in women. [1] [2] A slow heart rate is common under various circumstances and does not necessarily require treatment unless it causes symptoms. Nonetheless, some patients, even if asymptomatic, may require interventions to prevent life-threatening complications. This topic focuses on electrical causes of bradycardia.
Epidemiology
Sinus node dysfunction occurs in 1 in 600 patients per year over the age of 65 years. [15] The incidence of symptomatic atrioventricular block is probably as common. There are no good epidemiological data and the incidence and prevalence of bradycardia is unknown; however, in clinical practice, it may occur in both sexes equally and is more common in older people. There are no known data on global differences. The percentage of patients who require therapy is not completely certain.
Aetiology
Bradycardia is due to sinus node dysfunction or conduction system disease, the causes of which may be intrinsic or extrinsic. Intrinsic causes include degenerative processes, congenital abnormalities, direct tissue damage,
tissue inflammation or infiltration, infections (e.g., typhoid fever, diphtheria, tuberculosis, toxoplasmosis, rheumatic fever, or viral myocarditis), or abnormal autonomic effects. Extrinsic causes include exposure to toxins (e.g., lead, black widow spider venom, or tricyclic antidepressant overdose), drugs (e.g., digoxin, beta-blockers, calcium-channel blockers, or class I or III antiarrhythmics), or electrolyte abnormalities. [3] [16]Some causes, such as hypothyroidism, electrolyte disorders, and those that are drug-induced, are reversible. Inferior wall myocardial infarction and increased intracranial pressure can also cause various types of bradycardia. High vagal tone in an otherwise healthy young adult is a common cause of sinus bradycardia and Mobitz I (rarely Mobitz II) atrioventricular (AV) block. This may even manifest during sleep and may be exacerbated by sleep apnoea. Generalised conduction system disease related to calcification and fibrosis is called Lev's disease (or Lenegre-Lev syndrome) and is a cause of acquired complete heart block. Lev's disease is seen most commonly in older people and is often described as senile degeneration of the conduction system.
Pathophysiology
The cellular mechanisms are complex and interrelated. Failure of any one of these mechanisms can have an effect on heart rate. Normal cardiac electrical activation requires normal sinus node automaticity and effective AV node and His-Purkinje conduction. Anything that causes sinus node automaticity or conduction through the AV node and/or His-Purkinje system can cause bradycardia.
Classification
Clinical classification Bradycardia can be classified as asymptomatic or symptomatic. Asymptomatic patients often do not require treatment. Bradycardia classification Bradycardia can be classified according to the site of the conduction disturbance. [3] Sinus node dysfunction
Sinus bradycardia: heart rate below 50 bpm. It can be a normal finding, especially during rest or sleep, or can be abnormal and symptomatic. [4] Sinus nodal pauses/arrest: episodic, abrupt termination of sinus rhythm generally lasting longer than 3 seconds. Episodes can last longer than 30 seconds. There can be haemodynamic collapse, loss of blood
pressure, and/or loss of consciousness. The term sinus arrest is used generally for long sinus node pauses (i.e., >5 seconds). [5] Sinus nodal exit block: sinus node continues to activate but electrical activation is delayed and either blocked completely or incompletely between the sinus node and the atria. There can be various levels of block (e.g., complete or intermittent block). [6] Tachycardia-bradycardia syndrome: occurs when there are episodic periods of tachycardia (usually atrial flutter, atrial fibrillation, or atrial tachycardia), followed by termination of the tachycardia leading to sinus arrest or long sinus pauses, followed by sinus bradycardia. [7] Chronotropic incompetence: a form of bradycardia in which the sinus rate does not accelerate appropriately with exercise. [8] Sick sinus syndrome: a condition in which sinus node dysfunction manifests as one of the above abnormalities and there is evidence of slowing of sinus node function. Although this is generally not due to autonomic abnormalities, they can contribute. Some patients have marked bradycardia owing to sinus node dysfunction only after medicines that slow the sinus node are initiated. Sick sinus syndrome has been associated with atrioventricular (AV) nodal conduction abnormalities and a high risk of systemic embolism. [9]
AV conduction disturbance AV block occurs when atrial depolarisation fails to reach the ventricles or when atrial depolarisation is conducted with a delay.
First-degree AV block: delay in AV conduction, such that the PR interval is over 0.2 seconds. During first-degree AV block, there is one-to-one conduction but there is delay in AV nodal conduction. [10] It is not necessarily associated with bradycardia but it may be associated with higher degrees of AV block and subsequent bradycardia or sinus node dysfunction. types: o Mobitz I: grouped beating with a constant PP interval, lengthening in the PR interval and changing (usually shortening) RR intervals with the cycle ending with a P-wave and not followed by a QRS complex. As the PR interval gradually prolongs, the RR interval tends to stay the same or shorten. [11] Also called Wenckebach AV block. o o Mobitz II: associated with single non-conducted P-waves with a constant PP interval and constant PR intervals (no change in the PR above 0.025 seconds). [12] 2:1 block: only one PR interval to examine before the blocked P-wave and 2 P-waves for every QRS complex. In most cases, it will change to Mobitz I or II. If there is an associated bundle branch block, this suggests block in the His-Purkinje system. o High-degree AV block: more than one sequentially blocked P-wave. [13] Second-degree AV block: periodic failure of conduction from the atria to the ventricles. This assumes that the atrial rate is regular. A blocked premature atrial beat is not second-degree AV block. There are different
Third-degree AV block: occurs when there are no conducted impulses from the atria to the ventricles. Also called complete AV block. This may occur with regular atrial activity without conduction or with an atrial tachyarrhythmia.
Paroxysmal AV block: normal AV nodal conduction followed by sudden block of AV conduction associated with a long pause and multiple blocked P-waves, with subsequent resumption of AV conduction. This can be related to underlying AV nodal or His-Purkinje conduction anomalies or to abrupt parasympathetic activation causing block in AV nodal conduction. In the latter instance, there is often slowing in sinus activation.
Vagotonic AV block: slowing of the sinus node with prolongation of the PR interval followed by AV block owing to transient abrupt increase in parasympathetic tone.
Congenital complete heart block: usually associated with a narrow QRS complex escape rhythm arising in the AV node.
Escape rhythms When the sinus rate slows or there is AV block, other cardiac structures can activate owing to their intrinsic automaticity. The AV nodal rate tends to be 40 to 60 bpm and the ventricular rate tends to be 20 to 40 bpm.
Atrial rhythm: originates from atrial structures other than the sinus node during sinus bradycardia or sinus arrest. Junctional rhythm: escape rhythm when there is bradycardia or arrest of sinus node or atrial activation. Activation of the junction may occur with or without AV block. [14] Ventricular rhythm: an escape rhythm from the ventricles when there is AV block or sinus bradycardia.
AV dissociation
Atrial and ventricular activation occur from different pacemakers. Ventricular activation may be from junctional or infranodal automaticity. AV dissociation can occur in the presence of intact AV conduction, especially when rates of the pacemaker, either junctional or ventricular, exceed the atrial rate. The atria and ventricles do not activate in a synchronous fashion but beat independent of each other. Usually, the ventricular rate is the same or faster than the atrial rate. When the atrial rate is faster and the atria and ventricles are beating independently, complete heart block is present. AV dissociation can be complete or incomplete. When incomplete, some P-waves conduct and capture the ventricles but, if they do not, it is complete. Complete AV dissociation mimics AV block and has to do with Pwave timing in relation to independent ventricular activation. There are 2 types
Isorhythmic: when the atrial rate is the same (or nearly the same) as the ventricular rate but the P-wave is not conducted.
o ventricles.
Interference: when P-waves and QRS rates are similar but, occasionally, the atria conduct to the
Screening
Screening for bradycardia is not carried out normally because treatment is usually administered for symptomatic patients only. Patients may present with conditions that potentially predispose to bradycardia during routine clinic visits and these can be identified easily based on a review of the patient's medical history (e.g., hypothyroidism, medicines, and history of myocardial infarction). Treatment is not offered unless the vital signs (hypotension and bradycardia) suggest that the patient is, or may be at risk of, lightheadedness, syncope, or other complications. Screening ECGs and Holter monitoring may be considered for special patient populations, such as those with muscular dystrophies (e.g., myotonic dystrophy, Kearns-Sayre's syndrome, peronoeal muscular dystrophy, or limb-girdle muscular dystrophy), which affect the conduction system of the heart specifically. Findings of bundlebranch block and fascicular block with bradycardia in these patients, even though asymptomatic, should be followed-up aggressively because these patients can have unpredictable progression to complete heart block and sudden death. [35]
Secondary prevention
Regular evaluation and examinations are necessary, and patient reporting of suspicious symptoms is the best way to diagnose problems with bradycardia. Patients should guide practitioners regarding their symptoms and medicines that may be associated with bradycardia.
Key risk factors include history of taking medicines known to cause bradycardia, age over 70 years, previous myocardial infarction, surgery, hypothyroidism, sleep apnoea, exposure to toxins, infections, infiltrative diseases, and electrolyte disorders.
Palpation of peripheral pulse or cardiac auscultation may reveal a slow, regular heart beat of below 50 bpm or an irregular pulse of varying intensity.
dizziness/lightheadedness (common)
Occurs owing to bradycardia-induced cerebral hypoperfusion, especially in the setting of left ventricular dysfunction.
syncope (common)
Syncope is possible with long sinus nodal pauses or very slow heart rates. Occurs owing to bradycardia-induced cerebral hypoperfusion, especially in the setting of left ventricular dysfunction.
Common in patients with complete heart block and a very slow ventricular escape rhythm with left ventricular dysfunction and in patients with second-degree atrioventricular (AV) block.
fatigue (common) Many patients complain of worsening fatigue. exercise intolerance (common) May be owing to sinus node, AV node, or His-Purkinje system disease. shortness of breath (common) May be owing to sinus node, AV node, or His-Purkinje system disease. cannon a-waves in jugular venous pulse (common)
Patients with bradycardia secondary to complete heart block can have intermittent cannon a-waves in their jugular venous pulse noted, owing to atrial contraction against a closed tricuspid valve. Similarly, there may be a variable S1 during complete AV block.
During a junctional or ventricular rhythm with 1:1 V-to-A conduction, there may be cannon a-waves for each heart beat.
Owing to heart failure caused by bradycardia. Other diagnostic factorshide all increased intracranial pressure (common)
Sinus bradycardia can be noted as part of Cushing's triad (hypertension, bradycardia, and irregular respirations) related to raised intracranial pressure.
Because bradycardia can contribute to heart failure, patients may have a third heart sound and
Class I antiarrythmics (sodium channel blockers such as quinidine, disopyramide, lidocaine, phenytoin, fleicanide, propafenone), class III antiarrhythmics (potassium channel blockers such as amiodarone, sotalol, dofetilide), digoxin, beta-blockers, and calcium-channel blockers can cause bradycardia. [3] The effect is often dose- and drug-level-dependent, which, in turn, will depend on factors affecting drug metabolism, such as patient age, renal function, and hepatic function.
Other non-cardiac medicines that can cause bradycardia include: clonidine, calcium chloride, calcium gluconate, lithium, reserpine, methyldopa, opioids, benzatropine, paclitaxel, topical ophthalmic beta-blockers, phenytoin, cimetidine, thalidomide, dimethyl sulphoxide, topical ophthalmic acetylcholine, fentanyl, alfentanil, sufentanil, and cholinesterase inhibitors.
Drugs that contribute to atrioventricular (AV) block and/or sinus node dysfunction may only be uncovering an underlying 'occult' problem. [17]
Older patients are at greater risk for developing sinus node dysfunction and AV nodal disease, which are the major causes of bradycardia in this patient cohort.
In general, bradycardia is related to degeneration of the conduction system and the sinus node and changes in autonomic tone, which tends to worsen with age. [9][18] [19] [20]
Acute myocardial infarction can cause bradycardia by causing conduction block in the AV node (inferior infarction) or the His-Purkinje system (anterior infarction). [3] [21] [22] [23]
Sinus bradycardia and AV block owing to inferior infarction is often caused by the Bezold-Jarisch reflex (i.e., a transient increased vagal activation). Consequently, bradycardia following inferior infarction often resolves. Generally, the bradycardia caused by AV block in the His-Purkinje system owing to anterior wall myocardial infarction does not resolve.
Acute thrombosis of a coronary artery supplying the sinus or AV node can cause bradycardia, although permanent AV block is generally caused by anterior infarction affecting the bundle of His.
Common causes for sinus bradycardia and AV block in the setting of acute myocardial infarction include the use of beta-blockers, calcium-channel blockers, antiarrhythmics, and morphine; high levels of pain; increased vagal tone (especially following inferior infarction); and atrial ischaemia.
surgery
Sinus bradycardia is common intra-operatively owing to manoeuvres that increase vagal tone, such as intubation. If intra-operative hypothermia is planned, sinus bradycardia will almost certainly occur. It may also occur after hydrogen peroxide irrigation during neurosurgery.
Sinus bradycardia is also common postoperatively, mainly owing to pain, use of opioids, or the effects of the surgery itself.
Bradycardia can be due to injury to the sinus node during heart-transplant surgery. Sinus node disease can become apparent after a Mustard procedure for transposition of the great arteries and repair of an atrial septal defect.
AV block can occur after mitral valve and/or aortic valve surgery and after ventricular septal defect repair.
hypothyroidism
Sinus bradycardia is usually noted in patients with significant hypothyroidism, whether or not they have other symptoms of the disease, including signs and symptoms of congestive heart failure. [3]
electrolyte disorders
Hyperkalaemia, hypokalaemia, hypercalcaemia, and hypocalcaemia can cause bradycardia. Hyperkalaemia tends to be the most common abnormality seen; it causes bradycardia by causing a sinoventricular rhythm or AV block. [3]
Should be screened for in all patients with bradycardia because they are easily correctable. infections
Typhoid fever, diphtheria, tuberculosis, toxoplasmosis, rheumatic fever, viral myocarditis and Lyme disease have all been associated with bradycardia.
exposure to toxins
Lead exposure, black widow spider venom, and tricyclic antidepressant overdose have all been associated with bradycardia.
infiltrative diseases
Infiltrative disease, such as amyloidosis, Chagas' disease, or haemochromatosis, may also affect the conduction system of the heart, causing bradycardia.
sleep apnoea
Sinus node arrest, sinus bradycardia, and second-degree AV block are all manifestations of sleep apnoea.
Diagnostic tests
1st tests to ordershow all
Test Result
12-lead ECG
may show sinus bradycardia with or without sinus arrhyth block with junctional or ventricular escape, His-Purkinje s and AV block in a setting of myocardial infarction; deep T precordium indicative of a neurological event may occur i bradycardia
exercise testing carotid sinus massage echocardiogram thyroid function tests basic metabolic panel cardiac markers serum digoxin level serum creatinine
pause of over 3 seconds with symptoms suggests cardioinh of carotid sinus hypersensitivity
underlying structural heart disease, such as ventricular fun disease elevated TSH in hypothyroidism
implantable-loop recorder Subcutaneous monitoring device used for the detection of cardiac arrhythmias. Typically implanted in the left parasternal or pectoral region.
Useful modality if a patient has intermittent symptoms suspected to be secondary to a bradyarrhythmia but with n ECG abnormalities and negative Holter and/or event monitoring. Safe and efficacious in these settings. [29] [30] Device is implanted by an electrophysiologist and can be used for monitoring for up to 18 months. Stores recorded ECG strips either when the device is activated by the patient or when activated automatically according to programmed threshold criteria. Periodic interrogation of the device can retrieve this information. Also useful to rule out bradyarrhythmia as a cause of the patient's symptoms by identifying normal sinus rhythm time of a symptom event of interest. Reduce/prevent recurrent symptoms. [29] May be used if severe sinus node dysfunction (e.g., sinus exit block, sinus pauses, sinus arrest, or tachy-brady syndrome) is suspected but cannot be documented. Particularly useful in diagnosing Mobitz I AV block. tilt-table testing syncope. Commonly used method is head-upright tilting, which causes dependent venous pooling and thereby provokes the autonomic response.
Used to evaluate the adequacy of the autonomic system, especially when there is suspicion of neurocardiogenic
electrophysiology testing cannot be diagnosed by non-invasive modalities. Testing can be useful in patients with AV block and no clear symptom association; in patients with symptoms of bradycardia and in whom AV block is suspected but not documented; and when the site of AV block cannot be determined reliably by surface tracings.
Recommended when symptoms cannot be correlated clearly and when significant bradyarrhythmias are suspect
His-ventricle interval of >100 milliseconds in a patient with bradycardia, even in the absence of symptoms, is a h risk finding.[31] [32] Overall, the role of electrophysiological testing for bradycardia is limited, owing to low sensitivity and specificity. Positive findings may not be the reason for symptoms. [33] [34] May be used if severe sinus node dysfunction (e.g., sinus exit block, sinus pauses, sinus arrest, or tachy-brady syndrome) is suspected but cannot be documented. Atrial pacing progressively shorter cycle lengths during an electrophysiology study can manifest Mobitz type I in subjects with normal or abnormal AV node conduction.
Asymptomatic patients with Mobitz II AV block may benefit from this test to localise the site of block and to guide therapy.
Useful to demonstrate the location of the block (i.e., AV node versus His-Purkinje system) in 2:1 and high-degree block.
Differential diagnosis
Condition Ventricular bigeminy Differentiating signs/symptoms Differentiating tests
Postpremature ventricular contraction (PVC) potentiation not present during sinus rhythm without PVCs.
ECG and rhythm strip correlated with pulse show a prematu each normal beat.
Atrial fibrillation
ECG shows absent P waves, presence of fibrillatory waves complexes. Rhythm strip may be useful.
Ventricular tachycardia
Echocardiogram shows large pericardial effusion or chambe respiratory variation of ventricular filling.
Sinus tachycardia.
History
The most important diagnostic factor is age. Older patients present frequently with bradycardia owing to disease in the sinus node, the atrioventricular (AV) node, or the His-Purkinje system. In the AV conduction system, age-related fibrosis and sclerosis (Lenegre-Lev's disease) account for AV block in almost half of the cases. Older patients in particular may also present with bradycardia associated with medicines that have AV-node-blocking properties, such as beta-blockers, calcium-channel blockers, and digoxin; therefore, a detailed drug history should be taken.
A history of infection, infiltrative diseases, increased intracranial pressure, electrolyte disorders, exposure to toxins, surgery, heart transplant, sleep apnoea, or myocardial infarction may be present. Sinus bradycardia is usually noted in patients with significant hypothyroidism, whether or not they have other symptoms of the disease. Asymptomatic or symptomatic sinus bradycardia may occur in association with hypothermia. One of the most common symptoms associated with bradycardia is dizziness or lightheadedness. Many patients also complain of worsening fatigue. Syncope is possible with long pauses or slow heart rates, especially in patients with complete heart block and a slow ventricular escape rhythm with left ventricular dysfunction or in patients with second-degree AV block. These symptoms generally occur owing to bradycardia-induced cerebral hypoperfusion, especially in the setting of left ventricular dysfunction. Exercise intolerance and shortness of breath is also common and may be due to sinus node, AV node, or His-Purkinje system disease. Chest pain is a rare presentation. Bradycardia can be asymptomatic, especially in younger individuals.
Physical examination
Examination is usually non-specific. Palpation of peripheral pulse or cardiac auscultation may reveal a slow, regular heart beat of below 50 bpm or an irregular pulse of varying intensity. Patients with bradycardia secondary to complete heart block can have intermittent cannon a-waves in their jugular venous pulse (JVP) owing to atrial contraction against a closed tricuspid valve. Similarly, there may be a variable S1 during complete AV block. During a junctional or ventricular rhythm with 1:1 V-to-A conduction, there may be cannon a-waves for each heart beat. Because bradycardia can contribute to heart failure, patients may have a third heart sound, rales, jugular venous distension, and abdominal and lower extremity oedema. Signs of hypothyroidism should be assessed (e.g., dry or coarse skin or hair, facial oedema). Poor cardiac output due to bradycardia may be manifest as hypotension, mental status changes, and/or pallor; the extremities may be cool to the touch.
ECG
A 12-lead ECG is the first test in the diagnosis of bradycardia, regardless of the suspected cause. It is simple and easy to perform and provides diagnostic information. ECG also offers important clues regarding underlying conditions that could have caused the bradycardia; however, it only gives a snapshot in time that may not be helpful for diagnosis if bradycardia or symptoms are intermittent. In this situation, ambulatory monitoring is needed to correlate symptoms to bradycardia. ECG result depends on the cause of bradycardia. Sinus node dysfunction
Sinus bradycardia: regular P-wave followed by QRS at a rate of below 50 bpm; ambulatory ECG monitoring is helpful to correlate symptoms with heart rate. Sinus nodal pauses or arrest: long RR cycle length, which is longer than the RR interval of the underlying sinus rhythm. View image Sinus nodal exit block: an absent P-wave and prolongation of the RR cycle length, usually twice the underlying sinus RR interval. Tachy-brady syndrome: episodic periods of tachycardia (usually atrial flutter, atrial fibrillation, or atrial tachycardia), followed by termination of the tachycardia leading to sinus arrest or long sinus pauses, followed by sinus bradycardia.View imageView imageView imageView image
AV conduction disturbance
o First-degree AV block: fixed prolongation of the PR interval over 0.2 seconds. [10] View image Second-degree AV block: Mobitz I: grouped beating with a constant PP interval, lengthening in the PR interval and changing (usually shortening) RR intervals with the cycle ending with a P-wave not followed by a QRS complex. As the PR interval gradually prolongs, the RR interval tends to stay the same or shorten. [11] View imageView imageView image o o Mobitz II: associated with single non-conducted P-waves with a constant PP interval and constant PR intervals (no change in the PR of over 0.025 seconds). [12] View imageView image 2:1 AV block: only one PR interval to examine before the blocked P-wave and 2 P-waves for every QRS complex.View imageView image Block can be at the level of the AV node or the His-Purkinje system. If the QRS is narrow, the level of the block is probably in the AV node (which is more benign). If the QRS is wide (owing to bundle branch block or other conduction delay), block in the AV node is still most common but block in the His-Purkinje system is more frequent than when the QRS complex is narrow. o High-degree: more than one sequentially blocked P-wave. Block can be at the level of the AV node or the His-Purkinje system, as is the case with 2:1 AV block.
Third-degree AV block: occurs when there are no conducted impulses from the atria to the ventricles; shows no consistent PR relationship.View imageView image May occur with ventricular or junctional escape rhythm.View imageView imageView image
Paroxysmal AV block: normal AV nodal conduction followed by sudden block of AV conduction associated with a long pause and multiple blocked P-waves, with subsequent resumption of AV conduction.
Vagotonic AV block: slowing of the sinus node with prolongation of the PR interval followed by AV block owing to transient abrupt increase in parasympathetic tone.
Congenital complete heart block: usually associated with a narrow QRS complex escape rhythm arising in the AV node.
Escape rhythms may also occur in AV block, such as atrial (abnormal P-wave and decreased PR interval), junctional (above the bundle of His, produces a rate of approximately 40 to 60 bpm and narrow QRS complexes) View image and ventricular rhythms (below the bundle of His, produces a slower rate of 20 to 40 bpm and wide QRS complexes).
AV dissociation Independent activation of the atria and ventricles results in no fixed relationship between the P-waves and the QRS complexes. The PR intervals are variable in a random fashion. Ventricular rate is the same or faster than the atrial rate. There are 2 types:
Isorhythmic: when the atrial rate is the same (or nearly the same as the ventricular rate) but the P-wave is not conducted. Interference: when P-waves and QRS rates are similar but, occasionally, the atria conduct to the ventricles. View imageView image
Laboratory investigations
There are no specific laboratory investigations used to diagnose bradycardia; however, initial work-up should include thyroid function tests and a complete metabolic panel to rule out electrolyte disturbances, particularly hyperkalaemia, hypokalaemia, hypercalcaemia, and hypocalcaemia. Cardiac enzymes should be obtained if bradycardia is associated with ECG changes suggestive of myocardial infarction or ischaemia. Patients who have junctional bradycardia and who are prescribed digoxin should have their serum digoxin level checked. Patients with chronic bradycardia may have evidence of worsening renal function. Any additional laboratory testing should be guided by information obtained by history and physical examination to aid identification of the underlying cause.
Event monitoring
Widely used in the diagnosis of symptomatic bradycardia and can be worn for up to 30 days. Earlier designs were patient-triggered and so relied on the patient being able to recognise their symptoms and activate the monitor in a timely manner. This issue has been corrected to some extent by newergeneration monitors with auto-triggering capability and implantable loop recorders. Shows sinus pauses, sinus arrest, second- or third-degree AV block, or severe sinus bradycardia with symptoms. May be used if severe sinus node dysfunction (e.g., sinus exit block, sinus pauses, sinus arrest, or
tachy-brady syndrome) is suspected but cannot be documented. Particularly useful in diagnosing Mobitz I AV block.
Exercise testing
A sub-normal increase in heart rate after exercise (chronotropic incompetence) can be useful in diagnosing sick sinus syndrome. [24] [26] However, sensitivity and specificity are unclear and the results obtained may not be reproducible. [27] Even so, exercise-induced AV block, even if asymptomatic, can be significant and suggests disease of the His-Purkinje system. Identifying symptoms owing to sinus bradycardia can be difficult; however, exercise testing can be useful to help determine sinus node dysfunction as the cause of symptoms. Useful in determining level of block in Mobitz I.
Echocardiogram
Although it provides no direct diagnostic role for bradycardia, it provides valuable information regarding underlying heart disease that can influence management and decision making.Patients with significantly reduced left ventricular systolic function should be considered for an implantable cardioverter defibrillator if clinically appropriate.
Further investigations
Implantable loop monitor
A subcutaneous monitoring device used for the detection of cardiac arrhythmias. Typically implanted in the left parasternal or pectoral region.
Useful modality if a patient has rare symptoms that are difficult to record with non-invasive tools such as ECG, Holter monitors, and/or event monitors due to their infrequent nature, but are suspected to be secondary to a bradyarrhythmia. Safe and efficacious in these settings.[29] [30]
Also useful to rule out bradyarrhythmia as a cause of symptoms by identifying normal sinus rhythm at the time of a symptom event of interest.
May show sinus pauses, sinus arrest, second- or third-degree AV block, or severe sinus bradycardia with symptoms. May be used if severe sinus node dysfunction (e.g., sinus exit block, sinus pauses, sinus arrest, or tachy-brady syndrome) is suspected but cannot be documented. Particularly useful in diagnosing Mobitz I AV block.
Tilt-table testing
Used to evaluate adequacy of the autonomic system, especially when there is suspicion of neurocardiogenic syncope. A commonly used method is head-upright tilting, which causes dependent venous pooling and thereby provokes the autonomic response.
Electrophysiological testing
Recommended when symptoms cannot be correlated clearly and when significant bradyarrhythmias are suspected but cannot be diagnosed by non-invasive modalities. Electrophysiological measurements of sinus node function serve only as an adjunct to clinical and noninvasive parameters because these tests are based on assumptions that limit their validity and clinical utility. There is little utility for electrophysiology testing in already-documented second- and third-degree AV block. Testing can be useful in patients with AV block and no clear symptom association; in patients with symptoms of bradycardia in whom AV block is suspected but not documented; and when the site of AV block cannot be determined reliably by surface tracings. His-ventricle interval of over 100 milliseconds in a patient with bradycardia, even in the absence of symptoms, is a high-risk finding. [31] [32] Overall, the role of electrophysiological testing for bradycardia is limited, owing to low sensitivity and specificity. Positive findings may not be the reason for patient symptoms. [33][34] May be used if severe sinus node dysfunction (e.g., sinus exit block, sinus pauses, sinus arrest, tachybrady syndrome) is suspected but cannot be documented.
Atrial pacing at progressively shorter cycle lengths during an electrophysiology study can manifest Mobitz type I in subjects with normal or abnormal AV node conduction.
Asymptomatic patients with Mobitz II AV block may benefit from this test to localise the site of block and to guide therapy.
Useful to demonstrate the location of the block (i.e., AV node versus His-Purkinje system) in 2:1 and high-degree AV block.
Case history #1
An 85-year-old man presents with fatigue and episodes during which he feels he is going to pass out. He has no known heart disease. His ECG shows sinus bradycardia with a rate of 30 bpm and on a rhythm strip he has up to 5second pauses.
Case history #2
A 55-year-old man with hypertension and diabetes presents at the emergency department with complaints of dizziness and lightheadedness on exertion that has occurred gradually over the past month. He takes metoprolol (a beta-blocker) for hypertension. He is hypotensive and has a heart rate of 45 bpm. The rhythm strip shows Mobitz type II atrioventricular (AV) block with Q waves in the inferior leads. There are no previous ECGs.
Other presentations
Other diagnostic features include exercise intolerance and chest pain. Atypical presentations include elite athletes who present with sinus bradycardia, Mobitz I, or even Mobitz II atrioventricular (AV) block without symptoms owing to a conditioned heart. The condition could also manifest shortly after taking a beta-blocker, calcium-channel blocker, or digoxin in a patient with conduction system disease. Adolescents may not have any symptoms owing to preserved left-ventricular function; by contrast, older people are more likely to manifest symptoms because of structural heart disease.
Treatment Options
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
2nd
temporary pacing
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
node dysfunction
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
1st
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
mild symptoms
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response dysfunction is a result of a reversible or isolated
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response cause (e.g., specific medicine, electrolyte disorder,
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response or vasovagal event, such as taking blood),
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response hospitalisation is usually unnecessary.
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response ceasing drug treatment, administration of
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response electrolytes, or correction of thyroid dysfunction).
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
adjunct
theophylline
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
[?]
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response with mild symptoms, such as predominantly
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response exertional dizziness and/or fatigue. [38] [39]
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response Primary Options
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
1st
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response symptoms or sequelae, including syncope, near-
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response syncope, hypotension, marked fatigue, or
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response ventricular arrhythmias (including torsades de
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response pointes).
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response include specific medication, electrolyte disorder,
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response vasovagal events, and thyroid dysfunction.
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response chamber (DDD) pacing modes are all useful in
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response correcting bradycardia caused by sinus node
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response dysfunction, although the optimal pacing mode
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response remains controversial. Nonetheless, growing
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response evidence indicates that AAI, which avoids pacing
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response of the ventricle, is associated with a relatively
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response lower risk of atrial fibrillation and heart
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response failure. [35] [40]
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response risk of developing AV block or atrial fibrillation,
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response DDD pacemakers incorporating algorithms that
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response enable minimising ventricular pacing (functional
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response AAI pacing) are preferred over the single-lead AAI
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response system.
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response ventricular pacing in patients with systolic left
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response ventricular dysfunction may be associated with an
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response increased risk of atrial fibrillation, worsening heart
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response failure, and mortality secondary to left ventricular
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response desynchronisation. Therefore, pacing of the
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response ventricle should be avoided. [40] [41] Dual-
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response chamber pacemakers incorporating algorithms
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response that enable the minimisation of ventricular pacing
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response (functional AAI pacing) are preferred in patients
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response with systolic left ventricular dysfunction. [42]
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
1st
reassurance
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
mild symptoms
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response be reassured about their condition.
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
1st
permanent pacing
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
haemodynamically stable:
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
acquired AV block
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
1st
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response ceasing drug treatment, administration of
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response electrolytes, or correction of thyroid dysfunction).
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
1st
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response ceasing drug treatment, administration of
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response electrolytes, or correction of thyroid dysfunction).
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response present: high grade AV block, Mobitz II type,
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response evidence of infranodal block, catheter ablation of
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response the AV junction, persistent AV block after cardiac
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response surgery, or some neuromuscular diseases.
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response inhibited (VDD) pacing modes are useful in
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response correcting bradycardia caused by AV block.
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response Although the optimal pacing mode remains
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response controversial, modes that preserve atrioventricular
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response synchrony (VDD or DDD) are preferred. [35]
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
1st
reassurance
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response present: high grade AV block, Mobitz II type,
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response evidence of infranodal block, catheter ablation of
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response the AV junction, persistent AV block after cardiac
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response surgery, or some neuromuscular diseases.
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response asymptomatic, no specific treatment is required
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response and the patient can be reassured.
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
1st
permanent pacing
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
hemodynamically stable:
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
congenital AV block
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
1st
reassurance
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pacing
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response rhythm, complex ventricular arrhythmia, or
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response impaired systolic LV function. Although not agreed
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response universally, pacing should also be considered
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response strongly in asymptomatic patients with ventricular
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response escape rhythm of <50 bpm or prolonged
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response ventricular pauses. If these indications are absent,
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response no specific treatment is required and the patient
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response can be reassured.
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response in asymptomatic patients may improve survival.
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response However, whether or not all asymptomatic patients
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response with congenital AV block require permanent
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response pacemaker implantation remains controversial.
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
1st
permanent pacing
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
mediated bradycardia
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
1st
permanent pacing
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response recurrent symptoms who demonstrate a
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response hyperactive response to carotid sinus massage
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response (defined as ventricular asystolic pause of over 3
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response seconds), are thought to have symptoms owing to
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response hypersensitive carotid sinus, and have no other
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response explainable cause for syncope.
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
neurocardiogenic or vasovagal
1st
lifestyle modifications
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
syncope
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response lifestyle modification, regardless of the intrinsic
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response autonomic mechanism underlying syncopal
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response events.
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response identification and avoidance of precipitating
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response factors; measures to be taken during impending
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response events, such as lying down, elevation of legs, and
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response tensing manoeuvres; adequate fluid and salt
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response intake.
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
2nd
pharmacotherapy
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response been used; however, none of them have improved
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response outcome in prospective controlled trials. [43] [44]
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response who do not respond to lifestyle modifications. The
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response choice of the drug is made on an individual basis.
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response fludrocortisone, midodrine, and selective
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response serotonin-reuptake inhibitors (SSRIs).
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response Primary Options
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
3rd
permanent pacing
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response severe episodes of syncope refractory to medical
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response therapy who have significant bradycardia
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response documented during clinical events.
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response testing may not correlate with that during clinical
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response events and should be used with caution for the
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response selection of patients who may or may not benefit
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response from pacing.
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response syncope, the dual chamber (DDD) pacing mode is
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response considered to be the preferred pacing mode. The
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response value of programmable pacemaker features such
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response as rate-drop response, which have been designed
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response especially for neurocardiogenic syncope, remains
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response unclear. [43] [44]
pharmacotherapy
In patients with systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, angina, or life-threatening ventricular tachyarrhythmia, medical therapy should be started immediately until temporary cardiac pacing is initiated.
The most common medicines used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), or dopamine. All drugs are only marginally effective in providing sustained chronotropic support.
Their efficacy is limited to patients with sinus node dysfunction or conduction abnormalities at the level of the atrioventricular (AV) node. However, patients with infranodal conduction system disease may demonstrate further worsening bradycardia.
Dopamine should not be used in patients with lifethreatening tachyarrhythmias and should be used with caution in patients with ischaemic heart disease. Primary Options atropine : 0.5 to 1 mg intravenously as a bolus, repeat every 3-5 minutes as needed, maximum 3 mg total dose Secondary Options epinephrine : 2-10 micrograms/min intravenous infusion, titrate rate according to response OR dopamine : 2-10 micrograms/kg/min intravenous infusion, titrate rate according to response
Acute
Treatment approach
Management of bradycardia depends on multiple factors, such as the acuity and severity on presentation, the nature and reversibility of precipitating events, and underlying electrophysiological and cardiac abnormalities. Patients presenting with haemodynamic compromise, signs of cerebral hypoperfusion, progressive heart failure, or life-threatening arrhythmias secondary to bradycardia require urgent treatment. The most common reversible causes of bradycardia include drug-induced bradycardia related to drugs such as beta-blockers, calcium-channel blockers, and antiarrhythmic agents; increased vagal tone; and electrolyte abnormalities. The role of medicines in managing bradycardia is generally limited to emergency situations. Permanent pacing is the principal therapeutic modality for the management of persistent bradycardia.
be used as a sole temporary pacing modality to provide back-up in some patients with transient, infrequent, and short-lived episodes of bradycardia until a reversible cause is corrected or a permanent pacemaker is implanted. Transvenous pacing is the most secure and effective modality for patients who require continuous temporary pacing. The temporary pacing lead is usually placed on the right ventricle or, rarely, on the right atrium or both chambers using one of the central veins (femoral, subclavian, or internal jugular). A mechanical prosthetic tricuspid valve is a contraindication for right ventricular pacing. Complications are common (up to 20%) and related most commonly to venous access, infection, thromboembolism, heart perforation, or lead dislodgement. Ideally, pacing should not exceed more than a few days because of the incremental risk of infection.[36] [37]
All modern pacemakers are multi-programmable. The choice of the specific pacemaker mode is usually dictated by the underlying electrophysiological abnormality.
Permanent pacing is indicated only when any of the following are present: high-grade AV block, Mobitz type II, evidence of infranodal block, catheter ablation of the AV junction, persistent AV block after cardiac surgery, or some neuromuscular diseases. Patients who do not fit into any of these categories do not require treatment.
VVI, DDD, and VDD pacing modes are useful in correcting bradycardia caused by AV block. Although the optimal pacing mode remains controversial, modes that preserve AV synchrony (VDD or DDD) are preferred. [35]
Reversible cause
Underlying cause should be addressed (e.g., ceasing drug treatment, administration of electrolytes, or correction of thyroid dysfunction).
Non-reversible cause
Permanent pacing is the only available therapeutic modality for persistent acquired AV block that is a result of non-reversible causes. As a general rule, all symptomatic patients with AV block require permanent pacing regardless of the specific type or anatomical level of AV block. VVI, DDD, and atrial synchronous-ventricular inhibited (VDD) pacing modes are useful in correcting bradycardia caused by AV block. Although the optimal pacing mode remains controversial, modes that preserve AV synchrony (VDD or DDD) are preferred. [35]
wide QRS escape rhythm, complex ventricular arrhythmia, or impaired systolic LV function. Although not agreed universally, pacing should be considered strongly in asymptomatic patients with ventricular escape rhythm of below 50 bpm or prolonged ventricular pauses. Some data suggest that early institution of pacing in asymptomatic patients may improve survival. However, whether or not all asymptomatic patients with congenital AV block require permanent pacemaker implantation remains controversial. Pacing modes that preserve AV synchrony (VDD or DDD) are usually used. [35] Concomitant impaired systolic LV function
Patients need to be evaluated for possible ICD placement. Accumulating evidence suggests that right ventricular pacing in patients with systolic LV dysfunction may be associated with increased risk of atrial fibrillation, worsening heart failure, and mortality secondary to LV desynchronisation. Therefore, pacing of the ventricle should be avoided in patients with preserved AV conduction. [40] [41] The optimal pacing strategy for patients who require ventricular pacing (e.g., patients with AV block) remains unclear. Large randomised trials are underway to determine the role of cardiac re-synchronisation therapy and alternate right ventricle pacing sites in this category of patients.
The initial approach is usually based on education and lifestyle modification regardless of the intrinsic autonomic mechanism underlying syncopal events. The main aspects of this approach include:
o o
Identification and avoidance of precipitating factors Measures to be taken during impending events, such as lying down, elevation of legs, and tensing manoeuvres
Adequate fluid and salt intake. Data documenting specific therapy for vasovagal syncope are sparse. Multiple drugs with different mechanisms have been used with no or little documented benefit. [43] [44]Isolated studies demonstrating benefit of medical therapies, including fluoxetine, have been published. [45] New European guidelines advocate the use of midodrine for patients with vasovagal syncope refractory to lifestyle modifications. Beta-blocking agents are not indicated for the management of neurocardiogenic syncope and are considered third-line agents. [46]
Use of pacing is also of limited value. Pacing is reserved for patients with recurrent severe episodes of syncope refractory to medical therapy who have significant bradycardia documented during clinical events.
Heart-rate response observed during tilt-table testing may not correlate with that during clinical events and should be used with caution for the selection of patients who may or may not benefit from pacing.
When pacing is considered for neurocardiogenic syncope, the DDD pacing mode is considered to be the preferred pacing mode. The value of programmable pacemaker features such as rate-drop response, which have been designed especially for neurocardiogenic syncope, remains unclear. [43] [44]
Monitoring
Asymptomatic patients
Do not need regular follow-up. May monitor themselves as outpatients and notify their doctors only when they develop cardinal symptoms.
Symptomatic
Symptomatic patients should be seen by a physician, preferably a cardiologist, as soon as possible, with appropriate testing undertaken to establish the degree and mechanism of bradycardia and whether symptoms are secondary to the rhythm. Follow-up at this point depends on the type of diagnostic modality used. For example, if the patient has an event monitor, the follow-up should happen at the end of 30 days or before this if a patient transmission demonstrates a concerning rhythm correlating with symptoms.
Similarly, if a patient has an implantable-loop recorder, they should be followed up if a symptomatic episode occurred that caused the patient to activate the device. Routine follow-up in patients with implantableloop recorders can be every 3 to 6 months for the battery life of the device (i.e., usually 18 to 24 months).
Pacemaker implantation
A cardiologist, preferably an electrophysiologist, must follow up patients from when a pacemaker has been implanted. The initial follow-up should be 1 week after implant to assess the pocket and incision site for possible infection. 2-month follow-up must occur after pacemaker implantation and then yearly thereafter. The reason for frequent yearly follow-up is to assess the device for lead function and battery life, and to review any events that were recorded by the device.
Patient Instructions
Patient should be instructed to monitor heart rate and symptoms. It may be helpful for the patient to keep a symptom diary to record heart rate and blood pressure when symptomatic. Asymptomatic patients with bradycardia may monitor themselves as outpatients and notify their doctors only when they develop cardinal symptoms, such as dizziness, syncope, or exercise intolerance, or symptoms suggestive of congestive heart failure, so that therapy may be planned accordingly. For patients with a pacemaker, scheduled follow-up care is needed. Patients must check the pacemaker pocket site for bleeding and infection and notify their doctor immediately if these occur. Batteries may last between 5 and 10 years.
Complications
Complicationhide all
syncope see our comprehensive coverage of Assessment of syncope A common complication. Patients who experience syncope with bradycardia benefit from an implantable pacemaker to regulate the heart rhythm. congestive heart failure see our comprehensive coverage of Chronic congestive heart failure Some patients with longstanding bradycardia may develop symptoms of heart failure owing to decreased
cardiac output. Heart failure should be managed as for heart failure in any other condition. arrhythmias With complete heart block, patients may develop polymorphic ventricular tachycardia or ventricular fibrillation, which can cause sudden cardiac death.
Prognosis
Bradycardia may be an acute or chronic problem depending on the aetiology. It may resolve and never recur if the inciting event is treated or removed (e.g., hypothyroidism, electrolyte derangements, or medicines). However, for patients with an underlying conduction system disease, bradycardia will require frequent follow-up, with long-term and sometimes lifelong therapy with a pacemaker. The prognosis for patients who are symptomatic from bradycardia is poor if they are not treated with a pacemaker. Treatment with a pacemaker produces an excellent prognosis in these patients.