Clinical Review & Education

JAMA Cardiology Clinical Guidelines Synopsis

Evaluation and Treatment of Patients With Bradycardia

and Cardiac Conduction Delay
Keith Oken, MD; Mark H. Schoenfeld, MD; Fred Kusumoto, MD

GUIDELINE TITLE: 2018 ACC/AHA/HRS Guideline In patients with acquired second-degree Mobitz type II atrio-
on Bradycardia and Conduction Delay ventricular (AV) block, high-grade AV block, or third-degree AV
block not owing to reversible or physiologic causes, perma-
nent pacing is recommended regardless of symptoms.
DEVELOPERS: American College of Cardiology,
For all other types of AV block, in the absence of conditions
American Heart Association, Heart Rhythm Society associated with progressive AV conduction abnormalities,
permanent pacing should generally be considered only in the
RELEASE DATE: November 6, 2018 presence of symptoms that correlate with the AV block.
In patients with a left ventricular ejection fraction between
PRIOR VERSION: None 36% to 50% and AV block, who have an indication for perma-
nent pacing and are expected to require ventricular pacing
more than 40% of the time, techniques that provide more
MAJOR RECOMMENDATIONS: physiologic ventricular activation (cardiac resynchronization
Both sleep disorders of breathing and nocturnal bradycardias therapy or His-bundle pacing) are reasonable in preference to
are relatively common, and treatment of sleep apnea not only right ventricular pacing to prevent heart failure.
reduces the frequency of these arrhythmias but also may offer Using the principles of shared decision making and informed
cardiovascular benefits. The presence of nocturnal bradycar- consent and refusal, a patient with decision-making capacity
dias should prompt consideration for screening for sleep ap- or his or her legally defined surrogate has the right to refuse or
nea, starting with solicitation of suspicious symptoms, but is request withdrawal of pacemaker therapy, even if the patient
not in itself an indication for permanent pacing. is pacemaker dependent, which should be considered pallia-
The presence of left bundle branch block on electrocardio- tive end-of-life care rather than physician-assisted suicide or
grams markedly increases the likelihood of underlying struc- euthanasia. However, any decision is complex, should involve
tural heart disease and diagnosing left ventricular systolic all stakeholders, and will always be patient-specific.
dysfunction, and echocardiography is usually the most appro-
priate initial screening test for structural heart
disease, including left ventricular systolic dysfunction.
In sinus node dysfunction, there is no established minimum
heart rate or pause duration for which permanent pacing is
recommended; therefore, establishing a temporal correlation
between symptoms and bradycardia is important when decid-
ing on the necessity of permanent pacing.

Summary of the Clinical Problem Characteristics of the Guideline Source

Bradycardia and cardiac conduction abnormalities are common in The ACC, the AHA, and the HRS, in collaboration with the American
both health and disease. The evaluation and treatment for these con- Association for Thoracic Surgery, the Pediatric & Congenital Electro-
ditions can vary broadly based on symptoms, context, comorbidi- physiology Society, and the Society of Thoracic Surgeons, developed
ties including structural heart disease, and patient preferences. The this guideline. The 19 members of the guideline writing committee in-
2018 American College of Cardiology (ACC)/American Heart Asso- cluded cardiac electrophysiologists, cardiologists, surgeons, an anes-
ciation (AHA)/Heart Rhythm Society (HRS) Guideline on the Evalu- thesiologist,andarepresentativeoflaypersonsandpatients.Theguide-
ation and Management of Patients with Bradycardia and Cardiac Con- line underwent extensive peer review and was approved by the ACC/
duction Delay developed by the ACC, AHA, and HRS offers guidance AHA Task Force on Clinical Practice Guidelines, the ACC Board of
to clinicians for treating adult patients with bradycardia or cardiac Trustees, the AHA Science Advisory and Coordinating Committee, the
conduction system disorders, rather than technology-specific in- AHA Executive Committee, the HRS Scientific and Clinical Docu-
formation (Table).1 To our knowledge, the diagnostic evaluation of ments Committee, and the HRS Board of Trustees.
bradycardia and conduction disorders and the acute management
of bradycardia are topics that have not been addressed by prior Evidence Base
guideline documents, while the permanent pacemaker recommen- The recommendations in this guideline were based on extensive
dations are meant to supersede the pacemaker recommendations reviews of English-language literature derived from research involving
made in the 2012 ACCF/AHA/HRS Focused Update Incorporated Into human participants and indexed in MEDLINE (PubMed), Excerpta
the ACCF/AHA/HRS 2008 Guidelines for Device-Based Therapy of Medica Database (Embase), the Cochrane Library, the Agency for
Cardiac Rhythm Abnormalities.2 Healthcare Research and Quality, and other selected relevant data-

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 JAMA Cardiology Clinical Guidelines Synopsis Clinical Review & Education

bases. Key search words included AV block, bradycardia, bundle line can be considered in the presence of AV block and myocardial
branch block, conduction disturbance, left bundle branch block, loop re- infarction. In patients who require temporary pacing, temporary trans-
corder, pauses, permanent pacemaker, sick sinus syndrome, sinus node cutaneous pacing can also be considered as a temporizing measure.
dysfunction, and temporary pacemaker. However, in patients who will require prolonged periods of rate sup-
An independent evidence review committee composed of meth- port, temporary transvenous pacing or (if available and appropriate)
odologists, epidemiologists, clinicians, and biostatisticians was com- permanent pacing should be considered.
missioned to systematically survey, abstract, and assess the evidence
regarding 1 pivotal question: the potential role of physiologic pacing Discussion
(ie,biventricularpacingorHis-bundlepacing)inpatientswithaleftven- Althoughtheevidencebaseonwhichthisguidelineisfoundedislargely
tricularejectionfractiongreaterthan35%.Thefindingsoftheevidence observational or nonrandomized, it represents the best available data,
review committee were carefully considered by the writing commit- and the recommendations in this document should be helpful to a
tee in formulating the guideline recommendations.3 broad range of clinicians treating patients with bradycardia or cardiac
The writing committee compiled 476 references in an online conduction delay. The evaluation of such patients should focus on cor-
data supplement. Two of the 139 guideline recommendations were relating symptoms with arrhythmia, identifying and addressing revers-
based on a level of evidence A, 62 recommendations were based ible or physiologic causes, screening for underlying structural heart
on a level of evidence B, and 75 recommendations were based on a disease, and when clinically indicated, identifying comorbidities that
level of evidence C.4 To facilitate use of the guidelines at the bed- influenceprognosisand/ormanagement.Atropineisareasonablefirst-
side, the recommendations are supported by 1 or 2 concise para- line therapy for acute bradycardia requiring treatment.
graphs with the key references from the evidence base.
Areas in Need of Future Study or Ongoing Research
Benefits and Harms Over the past several years, there have been important technological
The guideline addresses selection and timing of diagnostic tools to as- advances and new procedural strategies, such as leadless pacing and
sess those with manifest or suspected bradycardia or conduction dis- His-bundlepacing,thathaveemergedforthetreatmentofpatientswith
orders. Key principles include efforts to identify and address reversible bradycardia. However, future research is required to identify how new
and physiologic causes of bradyarrhythmia, correlate symptoms with technology should be incorporated into management, and nuanced,
arrhythmia(oftenthroughprolongedambulatorymonitoring),andcon- patient-specific clinical decision-making is always required.
ductcarefulevaluationofstructuralheartdiseaseinpatientswithsymp-
tomatic arrhythmia, advanced degrees of atrioventricular (AV) block,
Related guidelines and other resources
or left bundle branch block. Management strategies differ depending
on the site of conduction system dysfunction, the degree of dysfunc-
2012 ACCF/AHA/HRS Focused Update Incorporated Into the
tion, the consequences (ie, symptoms) of dysfunction, and the context
ACCF/AHA/HRS 2008 Guidelines for Device-Based Therapy of
of the dysfunction, such as the presence of genetic, structural, infec- cardiac Rhythm Abnormalities: A Report of the American College
tious, infiltrative, metabolic, and/or systemic comorbidities. of Cardiology Foundation/American Heart Association Task Force
on Practice Guidelines and the Heart Rhythm Society
Acute Management of Bradycardia 2017 ACC/AHA/HRS Guideline for the Evaluation and Management
The initial management for bradycardia should focus on the presence of Patients With Syncope: A Report of the American College of
or absence of symptoms or reversible causes. In the presence of he- Cardiology/American Heart Association Task Force on Clinical Practice
modynamic compromise, atropine should be used first (except in re- Guidelines and the Heart Rhythm Society
cipients of heart transplants), followed by specific interventions if drug
2018 ACC/AHA/HRS Guideline for the Evaluation and Management
toxicity is present. For patients with a low likelihood of coronary ische- of Patients With Bradycardia and Cardiac Conduction Delay Data
mia, intravenous β-agonists can be considered for continued brady- Supplement
cardia associated with hemodynamic compromise, while theophyl-

ARTICLE INFORMATION of patients with bradycardia and cardiac conduction pacing versus right ventricular pacing among
delay. Circulation. 2018;pii:S0735-1097(18)38984-8. patients with left ventricular ejection fraction
Author Affiliations: Department of Cardiovascular
doi:10.1016/j.jacc.2018.10.043 greater than 35%: a systematic review for the 2018
Disease, Mayo Clinic, Jacksonville, Florida (Oken,
2. Epstein AE, DiMarco JP, Ellenbogen KA, et al; ACC/AHA/HRS guideline on the evaluation and
Kusumoto); Division of Cardiology, Department of
American College of Cardiology Foundation; management of patients with bradycardia and
Medicine, Yale University, New Haven, Connecticut
American Heart Association Task Force on Practice cardiac conduction delay, a report of the American
(Schoenfeld). College of Cardiology/American Heart Association
Guidelines; Heart Rhythm Society. 2012
Corresponding Author: Fred Kusumoto, MD, ACCF/AHA/HRS focused update incorporated into Task Force on Clinical Practice Guidelines and the
Department of Cardiovascular Disease, Mayo Clinic, the ACCF/AHA/HRS 2008 guidelines for Heart Rhythm Society. Heart Rhythm. 2018;
4500 San Pablo Ave, Jacksonville, FL 32224 device-based therapy of cardiac rhythm S1547-5271(18)31125-1.
([email protected]). abnormalities: a report of the American College of 4. Halperin JL, Levine GN, Al-Khatib SM, et al. Further
Published Online: April 24, 2019. Cardiology Foundation/American Heart Association evolution of the ACC/AHA Clinical Practice Guideline
doi:10.1001/jamacardio.2019.1069 Task Force on Practice Guidelines and the Heart Recommendation Classification System: a report of
Rhythm Society. J Am Coll Cardiol. 2013;61(3):e6-e75. the American College of Cardiology/American Heart
Conflict of Interest Disclosures: None reported. doi:10.1016/j.jacc.2012.11.007 Association Task Force on Clinical Practice Guidelines.
REFERENCES 3. Slotwiner DJ, Raitt MH, Del-Carpio Munoz F, J Am Coll Cardiol. 2016;67(13):1572-1574. doi:10.
Mulpuru SK, Nasser N, Peterson PN; Evidence 1016/j.jacc.2015.09.001
1. Kusumoto FM, Schoenfeld MH, Barrett C, et al. ACC/
AHA/HRSguidelineontheevaluationandmanagement Review Committee Members. Impact of physiologic

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