2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients with Bradycardia and Cardiac Conduction Delay

November 6, 2018 – The purpose of this guideline, accompanied by the Executive Summary and the Systematic Review, is to provide guidance to clinicians for the management of patients with bradycardia or symptoms thought to be associated with bradycardia or cardiac conduction system disorders.

This guideline supersedes the pacemaker recommendations made in the ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities and 2012 ACCF/AHA/HRS Focused Update Incorporated Into the ACCF/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. The guideline will be useful to general internists, family physicians, emergency physicians, anesthesiologists, surgeons, cardiologists, and arrhythmia specialists. This document is aimed at the adult population (>18 years of age) and offers no specific recommendations in pediatric patients, although some of the evidence review included pediatric patients.

Specific objectives and goals include the following:

• Describe the clinical significance of bradycardia with respect to mortality, symptoms (e.g., syncope, impaired functional capacity), and exacerbations of associated disorders (e.g., ischemia, heart failure, provoked tachyarrhythmias)
• Address inherited and acquired disorders of the sinus node, atrioventricular node, His-Purkinje fibers, and intramyocardial conducting tissue, including the effects of medications, aging, metabolic derangements, trauma, radiation, infiltrative, ischemic, and inflammatory disorders, infectious and toxic agents and iatrogenic factors
• Delineate the clinical presentation and general approach to clinical evaluation of patients with overt or suspected bradycardias or conduction diseases
• Comprehensively evaluate the evidence supporting recommendations for the selection and timing of available diagnostic testing modalities, including monitoring devices and electrophysiologic testing
• Address special considerations that may be applicable to distinct populations based on age (>18 years of age), comorbidities, or other relevant factors
• Identify knowledge gaps, pertinent trials in progress, and directions for future research