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
on Bradycardia and Conduction Delay
DEVELOPERS: American College of Cardiology,
American Heart Association, Heart Rhythm Society
RELEASE DATE: November 6, 2018
PRIOR VERSION: None
MAJOR RECOMMENDATIONS:
Both sleep disorders of breathing and nocturnal bradycardias
are relatively common, and treatment of sleep apnea not only
reduces the frequency of these arrhythmias but also may offer
cardiovascular benefits. The presence of nocturnal bradycar-
dias should prompt consideration for screening for sleep ap-
nea, starting with solicitation of suspicious symptoms, but is
not in itself an indication for permanent pacing.
The presence of left bundle branch block on electrocardio-
grams markedly increases the likelihood of underlying struc-
tural heart disease and diagnosing left ventricular systolic
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
Bradycardia and cardiac conduction abnormalities are common in
both health and disease. The evaluation and treatment for these con-
ditions can vary broadly based on symptoms, context, comorbidi-
ties including structural heart disease, and patient preferences. The
2018 American College of Cardiology (ACC)/American Heart Asso-
ciation (AHA)/Heart Rhythm Society (HRS) Guideline on the Evalu-
ation and Management of Patients with Bradycardia and Cardiac Con-
duction Delay developed by the ACC, AHA, and HRS offers guidance
to clinicians for treating adult patients with bradycardia or cardiac
conduction system disorders, rather than technology-specific in-
formation (Table).1 To our knowledge, the diagnostic evaluation of
bradycardia and conduction disorders and the acute management
of bradycardia are topics that have not been addressed by prior
guideline documents, while the permanent pacemaker recommen-
dations are meant to supersede the pacemaker recommendations
made in the 2012 ACCF/AHA/HRS Focused Update Incorporated Into
the ACCF/AHA/HRS 2008 Guidelines for Device-Based Therapy of
Cardiac Rhythm Abnormalities.2
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In patients with acquired second-degree Mobitz type II atrio-
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.
For all other types of AV block, in the absence of conditions
associated with progressive AV conduction abnormalities,
permanent pacing should generally be considered only in the
presence of symptoms that correlate with the AV block.
In patients with a left ventricular ejection fraction between
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
physiologic ventricular activation (cardiac resynchronization
therapy or His-bundle pacing) are reasonable in preference to
right ventricular pacing to prevent heart failure.
Using the principles of shared decision making and informed
consent and refusal, a patient with decision-making capacity
or his or her legally defined surrogate has the right to refuse or
request withdrawal of pacemaker therapy, even if the patient
is pacemaker dependent, which should be considered pallia-
tive end-of-life care rather than physician-assisted suicide or
euthanasia. However, any decision is complex, should involve
all stakeholders, and will always be patient-specific.
Characteristics of the Guideline Source
The ACC, the AHA, and the HRS, in collaboration with the American
Association for Thoracic Surgery, the Pediatric & Congenital Electro-
physiology Society, and the Society of Thoracic Surgeons, developed
this guideline. The 19 members of the guideline writing committee in-
cluded cardiac electrophysiologists, cardiologists, surgeons, an anes-
thesiologist,andarepresentativeoflaypersonsandpatients.Theguide-
line underwent extensive peer review and was approved by the ACC/
AHA Task Force on Clinical Practice Guidelines, the ACC Board of
Trustees, the AHA Science Advisory and Coordinating Committee, the
AHA Executive Committee, the HRS Scientific and Clinical Docu-
ments Committee, and the HRS Board of Trustees.
Evidence Base
The recommendations in this guideline were based on extensive
reviews of English-language literature derived from research involving
human participants and indexed in MEDLINE (PubMed), Excerpta
Medica Database (Embase), the Cochrane Library, the Agency for
Healthcare Research and Quality, and other selected relevant data-
jamacardiology.com
 JAMA Cardiology Clinical Guidelines Synopsis Clinical Review & Education

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

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

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