Heart Block and Bradycardia

Diagnosis/Definition

Palpitations, exercise intolerance, congestive heart failure (CHF), lightheadedness or syncope due to excessively slow heart rate.

Initial Diagnosis and Management

• History and physical exam: Hemodynamic consequences (e.g., syncope, CHF), rate slowing or atrioventricular (AV) nodal blocking medications.
• 12 lead electrocardiogram.
• PA and LAT CXR.
• Electrolytes, thyroid function.
• Document rhythm during symptoms: 24 hour holter monitor. For infrequent symptoms, an event recorder is performed only after three 24 hour holters (arranged through Cardiology).
• Discontinue rate slowing agents (e.g. digoxin, verapamil, diltiazem, beta blockers, clonidine).
• Syncope: Advise against driving or other activities where syncope would be harmful.
• Asymptomatic bradycardia: generally no treatment required, even for sinus pauses, first degree AV block, or Mobitz type I second degree AV block.
• Symptomatic bradycardia or heart block, or high grade AV block: usually hospitalized for initial management.

Ongoing Management and Objectives

• Elimination of rate slowing or AV nodal blocking agents may improve symptoms.
• Pacemaker implantation may improve symptoms and prevent syncope.

Indications for Specialty Care Referral

Bradycardiac patients with unexplained syncope should be referred for urgent evaluation.

Lightheadedness or exercise intolerance with documented bradycardia.

Documented Mobitz II second degree AV block, high grade AV block, or complete heart block.

Patients with pacemakers for pacemaker follow up.

Criteria for Return to Primary Care

Stable patients in whom pacemaker implantation is not required.

Stable pacemaker patients (except for pacemaker follow up)