eMedicine Specialties > Emergency Medicine > Cardiovascular

Sinus Bradycardia: Treatment & Medication

Author: Mark W Livingston, MD, Consulting Staff, Department of Emergency Medicine, Yakima Valley Memorial Hospital
Coauthor(s): David T Overton, MD, Professor, Chair, Program Director, Department of Emergency Medicine, Michigan State University, Kalamazoo Center for Medical Studies
Contributor Information and Disclosures

Updated: Aug 4, 2009

Treatment

Prehospital Care

  • Intravenous access, supplemental oxygen, and cardiac monitoring should be initiated in the field.
  • In symptomatic patients, intravenous atropine may be used.
  • In rare cases, transcutaneous pacing may need to be initiated in the field.

Emergency Department Care

  • Care in the ED should first rapidly ensure the stability of the patient's condition. This is followed by an investigation into the underlying cause of the bradycardia.
  • Patients in unstable condition may require immediate endotracheal intubation and transcutaneous or transvenous pacing.
  • Patients should have continuous cardiac monitoring and intravenous access.
  • In hemodynamically stable patients, attention should be directed at the underlying cause of the bradycardia.
  • In sick sinus syndrome, drug therapy approaches have been relatively disappointing. While atropine has aided some patients transiently, most patients ultimately require placement of a pacemaker. Guidelines on permanent pacing are available from the American College of Cardiology, American Heart Association, and Heart Rhythm Society.1
  • In patients with sinus bradycardia secondary to therapeutic use of digitalis, beta-blockers, or calcium channel blockers, simple discontinuation of the drug, along with monitored observation, are often all that is necessary. Occasionally, intravenous atropine and temporary pacing are required.
  • Treatment of postinfectious bradycardia usually requires permanent pacing.
  • In patients with hypothermia who have confirmed sinus bradycardia with a pulse, atropine and pacing are usually not recommended because of myocardial irritability. Rewarming and supportive measures are the mainstays of therapy.
  • Sleep apnea is usually treated with weight loss, nasal bilevel positive airway pressure (BiPAP) and, occasionally, surgery.

Medication

Drug treatment of sinus bradycardia is usually not indicated for asymptomatic patients. In symptomatic patients, underlying electrolyte or acid-base disorders or hypoxia should be corrected. Intravenous atropine may provide temporary improvement in symptomatic patients, although its use should be balanced by an appreciation of the increase in myocardial oxygen demand this agent causes.2

Although in the past, isoproterenol was used quite commonly in patients with bradycardia, further appreciation of its substantial risks has diminished its role. Temporary pacing is recommended in symptomatic patients who are unresponsive or only temporarily responsive to atropine, or in whom atropine therapy is contraindicated. Transcutaneous pacing, where available, is the initial procedure of choice.

Anticholinergics

These agents are indicated when symptoms of hypoperfusion exist. They are thought to work centrally by suppressing conduction in the vestibular cerebellar pathways. They may have an inhibitory effect on the parasympathetic nervous system.


Atropine (Atropair, Isopto)

Used to increase heart rate through vagolytic effects, causing increase in cardiac output.

Adult

0.5-1 mg IV or ET q3-5min up to 3 mg total (0.04 mg/kg)

Pediatric

0.02 mg/kg/dose IV, minimum of 0.1 mg

Other anticholinergics have additive effects; may increase pharmacologic effects of atenolol and digoxin; may decrease antipsychotic effects of phenothiazines; tricyclic antidepressants with anticholinergic activity may increase effects of atropine

Documented hypersensitivity; thyrotoxicosis; narrow-angle glaucoma; tachycardia

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid in Down syndrome and/or in children with brain damage to prevent hyperreactive response; avoid in coronary heart disease, tachycardia, congestive heart failure, cardiac arrhythmias, and hypertension; caution in peritonitis, ulcerative colitis, hepatic disease, and hiatal hernia with reflux esophagitis; patients with prostatic hypertrophy or prostatism can have dysuria and may require urinary catheterization

More on Sinus Bradycardia

Overview: Sinus Bradycardia
Differential Diagnoses & Workup: Sinus Bradycardia
Treatment & Medication: Sinus Bradycardia
Follow-up: Sinus Bradycardia
References
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References

  1. [Guideline] Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol. May 27 2008;51(21):e1-62. [Medline]. [Full Text].

  2. Grantham HJ. Emergency management of acute cardiac arrhythmias. Aust Fam Physician. Jul 2007;36(7):492-7. [Medline]. [Full Text].

  3. Bharati S, Nordenberg A, Bauernfiend R, Varghese JP, Carvalho AG, Rosen K, et al. The anatomic substrate for the sick sinus syndrome in adolescence. Am J Cardiol. Jul 1980;46(1):163-72. [Medline].

  4. Chokshi DS, Mascarenhas E, Samet P, Center S. Treatment of sinoatrial rhythm disturbances with permanent cardiac pacing. Am J Cardiol. Aug 1973;32(2):215-20. [Medline].

  5. Davies MJ, Pomerance A. Quantitative study of ageing changes in the human sinoatrial node and internodal tracts. Br Heart J. Feb 1972;34(2):150-2. [Medline].

  6. Ferrer MI. The sick sinus syndrome in atrial disease. JAMA. Oct 14 1968;206(3):645-6. [Medline].

  7. Gann D, Tolentino A, Samet P. Electrophysiologic evaluation of elderly patients with sinus bradycardia: a long-term follow-up study. Ann Intern Med. Jan 1979;90(1):24-9. [Medline].

  8. Krahn AD, Klein GJ, Norris C, Yee R. The etiology of syncope in patients with negative tilt table and electrophysiological testing. Circulation. Oct 1 1995;92(7):1819-24. [Medline].

  9. Kulbertus HE, De Leval-Rutten F, Demoulin JC. Sino-atrial disease: a report on 13 cases. J Electrocardiol. 1973;6(4):303-12. [Medline].

  10. Maisch B, Lotze U, Schneider J, Kochsiek K. Antibodies to human sinus node in sick sinus syndrome. Pacing Clin Electrophysiol. Nov 1986;9(6 Pt 2):1101-9. [Medline].

  11. Margolis JR, Strauss HC, Miller HC, Gilbert M, Wallace AG. Digitalis and the sick sinus syndrome. Clinical and electrophysiologic documentation of severe toxic effect on sinus node function. Circulation. Jul 1975;52(1):162-9. [Medline].

  12. Mills TA, Kawji MM, Cataldo VD, Pappas ND, O'Meallie LP, Breaux DM, et al. Profound sinus bradycardia due to diltiazem, verapamil, and/or beta-adrenergic blocking drugs. J La State Med Soc. Nov-Dec 2004;156(6):327-31. [Medline].

  13. Pollock G, Brady WJ Jr, Hargarten S, DeSilvey D, Carner CT. Hypoglycemia manifested by sinus bradycardia: a report of three cases. Acad Emerg Med. Jul 1996;3(7):700-7. [Medline].

  14. Rosenqvist M, Brandt J, Schüller H. Atrial versus ventricular pacing in sinus node disease: a treatment comparison study. Am Heart J. Feb 1986;111(2):292-7. [Medline].

  15. Sasaki Y, Shimotori M, Akahane K, Yonekura H, Hirano K, Endoh R, et al. Long-term follow-up of patients with sick sinus syndrome: a comparison of clinical aspects among unpaced, ventricular inhibited paced, and physiologically paced groups. Pacing Clin Electrophysiol. Nov 1988;11(11 Pt 1):1575-83. [Medline].

  16. Touboul P, Atallah G, Gressard A, Kirkorian G. Effects of amiodarone on sinus node in man. Br Heart J. Nov 1979;42(5):573-8. [Medline].

  17. Watt AH. Sick sinus syndrome: an adenosine-mediated disease. Lancet. Apr 6 1985;1(8432):786-8. [Medline].

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Further Reading

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Keywords

sinus bradycardia, vagal tone, bradycardia, inferior wall myocardial infarction, electrolyte disorders, tachycardia, sinus arrest, first-degree block, second-degree block, third-degree block, complete SA block, hypothermia, hypoglycemia, sleep apnea, diphtheria, rheumatic fever, viral myocarditis, digitalis glycosides, beta-blockers, calcium channel-blocking agents, class I antiarrhythmic agents, amiodarone, increased vagal tone, infection, hypothyroidism, increased intracranial pressure, sick sinus syndrome, cerebral hypoperfusion, sinoatrial block, SA block, carotid hypersensitivity, syncope, dizziness, shortness of breath, lightheadedness, chest pain, myocardial infarction, congestive heart failure, valvular failure

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Contributor Information and Disclosures

Author

Mark W Livingston, MD, Consulting Staff, Department of Emergency Medicine, Yakima Valley Memorial Hospital
Disclosure: Nothing to disclose.

Coauthor(s)

David T Overton, MD, Professor, Chair, Program Director, Department of Emergency Medicine, Michigan State University, Kalamazoo Center for Medical Studies
David T Overton, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Physician Executives, and American College of Physicians
Disclosure: Nothing to disclose.

Medical Editor

Daniel J Dire, MD, FACEP, FAAP, FAAEM, Clinical Professor, Department of Emergency Medicine, University of Texas-Houston; Clinical Professor, Department of Pediatrics, University of Texas Health Sciences Center, San Antonio, Texas
Daniel J Dire, MD, FACEP, FAAP, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, and Association of Military Surgeons of the US
Disclosure: Talecris Biotherapeutics Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gary Setnik, MD, Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School
Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD, Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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