Bradycardia

Highlights
Summary Overview

Basics
Definition Epidemiology Aetiology Pathophysiology Classification

Prevention
Screening Secondary

Diagnosis
History & examination Tests Differential Step-by-step Guidelines Case history

Treatment
Details Step-by-step Guidelines

Follow Up
Recommendations Complications Prognosis

Resources
References Images Patient leaflets Credits Email Print Feedback Share Add to Portfolio Bookmark Add notes

History & exam

Key factors
presence of risk factors pulse rate below 50 bpm dizziness/lightheadedness syncope fatigue

exercise intolerance shortness of breath cannon a-waves in jugular venous pulse jugular venous distension

Other diagnostic factors

increased intracranial pressure abnormal heart sounds abdominal or lower extremity oedema hypotension mental status changes pallor extremities cool to touch hypothermia chest pain History & exam details

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

pharmacotherapy permanent pacing Treatment details

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.

History & examination

Key diagnostic factorshide all
presence of risk factors (common)

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.

pulse rate below 50 bpm (common)

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.

jugular venous distension (common)

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.

abnormal heart sounds (uncommon)

Because bradycardia can contribute to heart failure, patients may have a third heart sound and

rales. abdominal or lower extremity oedema (uncommon)

Owing to heart failure caused by bradycardia. hypotension (uncommon) Manifestation of poor cardiac output owing to bradycardia. mental status changes (uncommon) Manifestation of poor cardiac output owing to bradycardia. pallor (uncommon) Manifestation of poor cardiac output owing to bradycardia. extremities cool to touch (uncommon) Manifestation of poor cardiac output owing to bradycardia. hypothermia (uncommon) Asymptomatic or symptomatic sinus bradycardia may occur in association with hypothermia. chest pain (uncommon)

Rare presentation of bradycardia.

Risk factorshide all

Strong use of known causative medications

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]

age over 70 years

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]

recent myocardial infarction

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

Holter monitoring event monitor

sinus pauses; sinus arrest; second- or third-degree AV bloc with symptoms

sinus pauses; sinus arrest; second- or third-degree AV bloc with symptoms

exercise testing carotid sinus massage echocardiogram thyroid function tests basic metabolic panel cardiac markers serum digoxin level serum creatinine

exercise-induced AV block; chronotropic incompetence

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

hypokalaemia or hyperkalaemia; hypocalcaemia or hyperc

elevation of CK, CK-MB, and troponin in myocardial infa

depends on dose and drug-metabolism factors; may be in t elevated

Tests to considerhide all

Test

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.

Cannon awaves seen in

the jugular venous pulse.

Frequent premature ventricular contractions (PVCs)

Non-perfused ventricular ectopy causing apparent sinus bradycardia.

ECG and rhythm strip correlated with pulse. Specific ECG f

cause. However, ventricular beats occur earlier than norma

Patients are usually asymptomatic .

Cannon awaves may be seen in the jugular venous pulse.

Atrial fibrillation

Apical versus peripheral pulse.

ECG shows absent P waves, presence of fibrillatory waves complexes. Rhythm strip may be useful.

Irregular pulse rate.

Blocked premature atrial contractions (PACs)

Atrial rate is fast but ventricular rate is slow.

ECG shows slight notching on preceding T-wave.

Ventricular tachycardia

A-waves, variable S1, and variable pulse seen in

ECG shows atrioventricular (AV) dissociation with capture a

jugular venous pressure. Cardiac tamponade

Muffled heart sounds.

ECG shows low voltage, QRS, or total electrical alternans.

Echocardiogram shows large pericardial effusion or chambe respiratory variation of ventricular filling.

Sinus tachycardia.

Pulsus paradoxus (usually below 10 mmHg).

Elevated jugular venous pressure.

Step-by-step diagnostic approach

A diagnosis of bradycardia is simple and is generally made on an ECG or telemetry monitor when there is slowing of the heart rhythm to below 50 bpm, even if only transient. The challenge is determining the aetiology of the bradycardia and determining the site at which there is reduction in impulse generation or propagation. The primary use of testing is to correlate symptoms with bradycardia and/or to establish a potentially dangerous condition as the cause of bradycardia, even though the patient may be asymptomatic.

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.

Other initial investigations

Holter or event monitoring, exercise testing, carotid sinus massage, and echocardiogram all form part of the initial work-up in addition to the ECG and are especially useful for intermittent bradycardia or patients with symptoms. If patients have sinus bradycardia, they should be further evaluated only if they are symptomatic or show evidence of haemodynamic compromise. Holter monitoring
Enables correlation of symptoms with episodes of bradycardia. Diagnostic clues are obtained in 50% to 70% of patients with bradycardia suspected on clinical grounds. [24] [25]However, events can be missed if symptoms do not occur in the 24- to 48-hour monitoring period. Asymptomatic bradycardia and pauses (especially nocturnal) are not uncommon in the normal heart and are probably non-diagnostic. Shows sinus pauses, sinus arrest, second- or third-degree AV block, or severe sinus bradycardia with symptoms. First-degree AV block or Mobitz type I AV block may be noted while patients are asleep owing to high vagal tone. 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. May help distinguish the location of the block (i.e., AV node versus His-Purkinje system) in 2:1 and highdegree AV block. A long-monitored strip should be run because 2:1 AV block is unlikely to persist. The other forms of AV block (Mobitz I or II) should then become apparent. Monitoring while the patient does some form of exertion (e.g., arm exercise, standing, and walking) may also help to demonstrate the level of block. Block at the level of the AV node should improve with the adrenergic stimulation but block below the AV node in the HisPurkinje system may worsen as AV nodal conduction improves and increases the frequency of inputs to the HisPurkinje system.

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.

Carotid sinus massage

Used during continuous ECG monitoring (after evaluating for the presence of carotid bruit by direct auscultation) in the evaluation of carotid sinus hypersensitivity, which causes symptomatic bradycardia and is associated with sick sinus syndrome. Diagnostic yield of carotid sinus massage can be increased by performing this during head-up tilting. [28] A pause of over 3 seconds with symptoms is indicative of a cardio-inhibitory response from carotid sinus hypersensitivity. Can help diagnose Mobitz I and II AV block; it will accentuate Wenckebach in the AV node but will have an opposite effect if the block is below the His bundle. May help distinguish the location of the block (i.e., AV node versus His-Purkinje system) in 2:1 and highdegree AV block. It may improve block in the His-Purkinje system by slowing the sinus and AV nodal inputs to the His-Purkinje system, enabling the His-Purkinje system longer in which to recover between inputs.

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.

Click to view diagnostic guideline references.

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Patients who are not responsive to medical

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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: sinus

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

reversible cause: asymptomatic or

1st

treatment of underlying cause

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

For mild symptoms or when sinus node

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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,

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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),

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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.

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Underlying cause should be addressed (e.g.,

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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).

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

[?]

Theophylline may be used in selected patients

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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]

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

reversible cause: severe symptoms

1st

treatment of underlying cause + temporary pacing

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Temporary pacing is needed if there are severe

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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-

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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).

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Underlying causes should be corrected and

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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,

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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.

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Atrial-based (AAI), ventricle-based (VVI), and dual

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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]

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Because patients with sinus node disease are at

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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,

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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.

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Accumulating evidence suggests that right

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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-

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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]

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

irreversible cause: asymptomatic or

1st

reassurance

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

No specific treatment is required, and patients can

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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.

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

irreversible cause: severe symptoms

1st

permanent pacing

Acute treatment is needed if there are severe

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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:

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

reversible cause: asymptomatic

1st

treatment of underlying cause

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

without indications for pacing

The underlying cause should be addressed (e.g.,

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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).

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

reversible cause: symptomatic or

1st

treatment of underlying cause + temporary pacing

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

indications for pacing

The underlying cause should be addressed (e.g.,

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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).

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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 is indicated when any of the following is

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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,

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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.

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

VVI, DDD, and atrial synchronous-ventricular

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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.

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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]

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

irreversible cause: asymptomatic

1st

reassurance

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

without indications for pacing

Pacing is indicated when any of the following is

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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,

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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.

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

If these indications are absent and the patient is

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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.

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

irreversible cause: symptomatic or indications for pacing

1st

permanent pacing

Pacing is indicated when any of the following is

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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:

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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 without indications for

1st

reassurance

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Indications for pacing include wide QRS escape

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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,

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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.

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Some data suggest that early institution of pacing

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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.

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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.

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

symptomatic or indications for pacing

1st

permanent pacing

There is a general consensus that pacing is

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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: vagally

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

carotid hypersensitivity syndrome

1st

permanent pacing

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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 may be indicated for patients with

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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.

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Initial approach is usually based on education and

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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.

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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 main aspects of this approach include:

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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.

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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 role of medicine is limited.

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Multiple drugs with different mechanisms have

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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]

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Medical therapy is usually considered in patients

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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.

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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 most commonly used drugs are

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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).

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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 is reserved for patients with recurrent

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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.

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Heart-rate response observed during tilt-table

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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.

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

When pacing is considered for neurocardiogenic

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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]

Treatment Patient group haemodynamically unstable line 1st Treatmenthide all

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.

Haemodynamically unstable patients

Bradycardia associated with haemodynamic compromise (i.e., systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure, or angina) or life-threatening ventricular tachyarrhythmia represents a true medical emergency. Medical therapy should be started immediately, regardless of the cause, and continued until temporary cardiac pacing is initiated. The most common medications used to increase ventricular rate are intravenous atropine, epinephrine (adrenaline), and dopamine. Some clinicians use isoprenaline, as it is the strongest beta agonist. However, isoprenaline may perpetuate hypotension, if present, due to its vasodilation effects, and so is not generally recommended. Epinephrine (adrenaline) on the other hand, due to its combined alpha and beta agonist properties, may help increase blood pressure as well as heart rate. Patients who are not responsive to medical therapy require prompt temporary pacing. The 2 most commonly used modes of temporary pacing are transcutaneous and transvenous. Transcutaneous pacing can be applied rapidly through external adhesive electrodes. However, this pacing modality usually serves as a bridge to transvenous pacing because it causes painful skeletal muscle stimulation and usually requires sedation. Furthermore, the efficacy of transcutaneous pacing to provide stable ventricular capture is limited to 78% to 94%. [36] [37]It can

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]

Haemodynamically stable patients: general approach

These patients are treated according to the underlying cause and usually require either temporary or permanent pacing, depending on whether sinus node dysfunction or atrioventricular (AV) conduction disturbance is present. Permanent pacing is the only available therapeutic modality for persistent bradycardia owing to non-reversible causes. Pacing modes are described by a 5-letter code.
The first letter designates the chamber that is paced (O is none; A is atrium; V is ventricle; D is dual chamber). The second letter is the chamber in which sensing occurs (O is none; A is atrium; V is ventricle; D is dual chamber). The third letter is the response to sensed event (O is none; I is inhibition; T is triggered; D is both inhibition and triggering). The fourth letter usually refers to the rate response (R). The fifth letter refers to anti-tachycardia capabilities and is not used commonly.

All modern pacemakers are multi-programmable. The choice of the specific pacemaker mode is usually dictated by the underlying electrophysiological abnormality.

Haemodynamically stable: sinus node dysfunction

Asymptomatic patients
No specific treatment, including pacing, is required for patients with asymptomatic sinus node dysfunction. [35]

Reversible cause or mild symptoms

In patients with sinus node dysfunction owing to a reversible or isolated cause (e.g., specific medicine, electrolyte disorder, or vasovagal event, such as taking blood), underlying cause should be addressed (e.g., stopping responsible drug, correction of electrolyte abnormality, regulation of thyroid dysfunction). Theophylline may be used in selected patients with mild symptoms, such as predominantly exertional dizziness and/or fatigue. [38] [39]

Non-reversible cause or severe symptoms

Acute treatment is needed if there are severe symptoms or sequelae, including syncope, near-syncope, hypotension, marked fatigue, or ventricular arrhythmias (including torsades de pointes). Hospitalisation is generally required because permanent pacing is the treatment of choice. The role of pharmacotherapy is limited in this situation. AAI, VVI, and DDD pacing modes are all useful in correcting bradycardia caused by sinus node dysfunction, although the optimal pacing mode remains controversial. Nonetheless, growing evidence indicates that AAI, which avoids pacing of the ventricle, is associated with a relatively lower risk of atrial fibrillation and heart failure. [35] [40] Because patients with sinus node disease are at risk of the development of AV block or atrial fibrillation, DDD pacemakers incorporating algorithms that enable the minimisation of ventricular pacing (functional AAI pacing) are preferred over the single-lead AAI system.

Concomitant impaired systolic left ventricular (LV) function

Patients need to be evaluated for possible implantable cardioverter defibrillator (ICD) placement. Accumulating evidence suggests that right ventricular pacing in patients with systolic LV dysfunction may be associated with an increased risk of atrial fibrillation, worsening heart failure, and mortality secondary to LV desynchronisation. Therefore, pacing of the ventricle should be avoided in patients who do not need it. [40] [41] Dual-chamber pacemakers incorporating algorithms that enable the minimisation of ventricular pacing (functional AAI pacing) are preferred in these patients. [42]

Haemodynamically stable: acquired AV block

Asymptomatic patients

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]

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 an 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.

Haemodynamically stable: congenital complete AV block

Treatment approach to patients with congenital complete AV block continues to evolve. There is a general consensus that pacing is indicated for all symptomatic patients or for asymptomatic patients with any of the following:

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.

Haemodynamically stable: vagally mediated bradycardia

Bradycardia mediated by increased vagal activation and peripheral vasodilation secondary to reduced sympathetic activity are integral parts of the neurocardiogenic response manifested by systemic hypotension. In this clinical situation, treating bradycardia in itself may be ineffective in alleviating symptoms in many patients with neurocardiogenic events. Understanding the relative contribution of the mechanisms in each individual case is critical in defining the therapeutic approach. Carotid sinus hypersensitivity syndrome
Pacing may be indicated for patients with recurrent symptoms who demonstrate a hyperactive response to carotid sinus massage (defined as ventricular asystolic pause of over 3 seconds), are thought to have symptoms owing to hypersensitive carotid sinus, and have no other explainable cause for syncope. Patients without these indications do not require treatment.

Neurocardiogenic or vasovagal syncope

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.