The Ten Commandments of Bradycardia Management by ACC/AHA Guideline

The American College of Cardiology, the American Heart Association, and the Heart Rhythm Society have just released new guidelines for the evaluation and treatment of patients with bradycardia and cardiac conduction disorders.

 Bradycardia, defined as a heart rate of less than 50 beats a minute, can limit the amount of blood and oxygen that is pumped into our organs. Cardiac conduction disorders occur when electrical impulses in the heart are delayed resulting in a slow heartbeat.

The 10 take-home messages for the management of bradycardia and cardiac conduction delay as per these new guidelines include:

1.Sinus node dysfunction is related to age-dependent progressive fibrosis of the sinus nodal tissue, and any abnormalities of the sinus node will result in bradycardia.

2.The presence of nocturnal bradycardia should prompt consideration for sleep apnoea screening even if it is not an indication for permanent pacing.

3. Echocardiography is the most appropriate initial screening test for structural heart disease.

4. Temporal correlation should be established between symptoms and bradycardia to determine if permanent pacing is needed.

5.Permanent pacing is recommended in patients with acquired second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block or third-degree atrioventricular block.

6. In patients with an LVEF between 36 to 50%, techniques that provide physiologic ventricular activation should be preferred over right ventricular pacing.

7. Post-procedure surveillance after TAVR and pacemaker implantation should be considered.

8. Shared decision-making and patient-centred care should be the key focus in all treatment decisions.

9.Decisions should involve all stakeholders and should always be patient-specific.

10.Patient populations that will benefit most from emerging pacing technologies should be identified.

The new guidelines also include recommendations on post-procedure surveillance after TAVR as well as pacemaker implantation. Finally, the importance of shared decision-making between patients and clinicians as well as a focus on patient-centred care are also highlighted in the new guidelines.

“Treatment decisions are based not only on the best available evidence but also on the patient’s goals of care and preferences,” said Fred M. Kusumoto, MD, cardiologist at Mayo Clinic Florida in Jacksonville and chair of the writing committee. “Patients should be referred to trusted material to aid in their understanding and awareness of the consequences and risks of any proposed action.”

The new guidelines are published in the Journal of the American College of Cardiology, Circulation and Heart Rhythm.

Source: AHA/ACA/Heart Rhythm Society