Sinus Bradycardia Treatment & Management

  • Author: Mark W Livingston, MD; Chief Editor: David FM Brown, MD   more...
 
Updated: Dec 22, 2010
 

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.

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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.

Sinus bradycardia may be seen in patients undergoing therapeutic hypothermia. These patients are likely to develop sinus bradycardia sometime during their course that will require close monitoring of perfusion status. If they show signs of adequate perfusion, no treatment is necessary. Treatment of inadequate perfusion would include pressors, atropine, and pacing.[2]

Sleep apnea is usually treated with weight loss, nasal bilevel positive airway pressure (BiPAP) and, occasionally, surgery.

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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  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.

Specialty Editor Board

Daniel J Dire, MD  FACEP, FAAP, FAAEM, Clinical Professor, Department of Emergency Medicine, University of Texas Medical School at Houston; Clinical Professor, Department of Pediatrics, School of Medicine, University of Texas Health Sciences Center San Antonio

Daniel J Dire, MD 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

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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; ProceduresConsult.com Royalty Other

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  Associate 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.

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. [Guideline] Field JM, Hazinski MF, Sayre MR, Chameides L, Schexnayder SM, Hemphill R, et al. Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. Nov 2 2010;122(18 Suppl 3):S640-56. [Medline].

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

  4. 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].

  5. 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].

  6. 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].

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

  8. 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].

  9. 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].

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

  11. 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].

  12. 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].

  13. 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].

  14. 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].

  15. 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].

  16. 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].

  17. 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].

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

 
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