-
Trends in Cardiovascular Medicine Jul 2020Bradycardia is a commonly observed arrhythmia and a frequent occasion for cardiac consultation. Defined as a heart rate of less than 50-60 bpm, bradycardia can be... (Review)
Review
Bradycardia is a commonly observed arrhythmia and a frequent occasion for cardiac consultation. Defined as a heart rate of less than 50-60 bpm, bradycardia can be observed as a normal phenomenon in young athletic individuals, and in patients as part of normal aging or disease (Table 1). Pathology that produces bradycardia may occur within the sinus node, atrioventricular (AV) nodal tissue, and the specialized His-Purkinje conduction system. Given the overlap of heart rate ranges with non-pathologic changes, assessment of symptoms is a critical component in the evaluation and management of bradycardia. Treatment should rarely be prescribed solely on the basis of a heart rate lower than an arbitrary cutoff or a pause above certain duration. In the 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients with Bradycardia and Cardiac Conduction Delay (referred to hereafter as the 2018 Bradycardia Guideline), there was a significant shift in emphasis from prior guidelines that emphasized device-based implantation recommendations to a focus on evaluation and management of disease states [1,2]. In this review, we will highlight the changes in the new guideline as well as describe the key elements in evaluation and management of patients presenting with bradycardia.
Topics: Action Potentials; Atrioventricular Block; Bradycardia; Cardiac Pacing, Artificial; Clinical Decision-Making; Heart Conduction System; Heart Rate; Humans; Pacemaker, Artificial; Patient Selection; Sick Sinus Syndrome; Treatment Outcome
PubMed: 31311698
DOI: 10.1016/j.tcm.2019.07.001 -
Circulation Aug 2019
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.
Topics: Adrenergic beta-Antagonists; Arrhythmias, Cardiac; Bradycardia; Cardiac Conduction System Disease; Electrocardiography; Electrophysiological Phenomena; Epilepsy; Heart Diseases; Humans; Myocardial Infarction; Quality of Life
PubMed: 30586772
DOI: 10.1161/CIR.0000000000000628 -
Anaesthesia Jul 2007The clinical features of propofol infusion syndrome (PRIS) are acute refractory bradycardia leading to asystole, in the presence of one or more of the following:... (Review)
Review
The clinical features of propofol infusion syndrome (PRIS) are acute refractory bradycardia leading to asystole, in the presence of one or more of the following: metabolic acidosis (base deficit > 10 mmol.l(-1)), rhabdomyolysis, hyperlipidaemia, and enlarged or fatty liver. There is an association between PRIS and propofol infusions at doses higher than 4 mg.kg(-1).h(-1) for greater than 48 h duration. Sixty-one patients with PRIS have been recorded in the literature, with deaths in 20 paediatric and 18 adult patients. Seven of these patients (four paediatric and three adult patients) developed PRIS during anaesthesia. It is proposed that the syndrome may be caused by either a direct mitochondrial respiratory chain inhibition or impaired mitochondrial fatty acid metabolism mediated by propofol. An early sign of cardiac instability associated with the syndrome is the development of right bundle branch block with convex-curved ('coved type') ST elevation in the right praecordial leads (V1 to V3) of the electrocardiogram. Predisposing factors include young age, severe critical illness of central nervous system or respiratory origin, exogenous catecholamine or glucocorticoid administration, inadequate carbohydrate intake and subclinical mitochondrial disease. Treatment options are limited. Haemodialysis or haemoperfusion with cardiorespiratory support has been the most successful treatment.
Topics: Acidosis; Adolescent; Adult; Anesthetics, Intravenous; Biomarkers; Bradycardia; Child; Child, Preschool; Death, Sudden; Female; Humans; Hypnotics and Sedatives; Infant; Male; Mitochondrial Diseases; Propofol; Risk Factors; Syndrome
PubMed: 17567345
DOI: 10.1111/j.1365-2044.2007.05055.x -
Journal of the American College of... Aug 2019
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.
Topics: Bradycardia; Cardiac Conduction System Disease; Cardiac Pacing, Artificial; Disease Management; Humans; Sleep Apnea Syndromes
PubMed: 30412709
DOI: 10.1016/j.jacc.2018.10.044 -
British Journal of Clinical Pharmacology Mar 2016Management of cardiovascular instability resulting from calcium channel antagonist (CCB) or beta-adrenergic receptor antagonist (BB) poisoning follows similar... (Review)
Review
Management of cardiovascular instability resulting from calcium channel antagonist (CCB) or beta-adrenergic receptor antagonist (BB) poisoning follows similar principles. Significant myocardial depression, bradycardia and hypotension result in both cases. CCBs can also produce vasodilatory shock. Additionally, CCBs, such as verapamil and diltiazem, are commonly ingested in sustained-release formulations. This can also be the case for some BBs. Peak toxicity can be delayed by several hours. Provision of early gastrointestinal decontamination with activated charcoal and whole-bowel irrigation might mitigate this. Treatment of shock requires a multimodal approach to inotropic therapy that can be guided by echocardiographic or invasive haemodynamic assessment of myocardial function. High-dose insulin euglycaemia is commonly recommended as a first-line treatment in these poisonings, to improve myocardial contractility, and should be instituted early when myocardial dysfunction is suspected. Catecholamine infusions are complementary to this therapy for both inotropic and chronotropic support. Catecholamine vasopressors and vasopressin are used in the treatment of vasodilatory shock. Optimizing serum calcium concentration can confer some benefit to improving myocardial function and vascular tone after CCB poisoning. High-dose glucagon infusions have provided moderate chronotropic and inotropic benefits in BB poisoning. Phosphodiesterase inhibitors and levosimendan have positive inotropic effects but also produce peripheral vasodilation, which can limit blood pressure improvement. In cases of severe cardiogenic shock and/or cardiac arrest post-poisoning, extracorporeal cardiac assist devices have resulted in successful recovery. Other treatments used in refractory hypotension include intravenous lipid emulsion for lipophilic CCB and BB poisoning and methylene blue for refractory vasodilatory shock.
Topics: Adrenergic beta-Antagonists; Antidotes; Bradycardia; Calcium Channel Blockers; Drug Overdose; Humans; Hypotension; Shock
PubMed: 26344579
DOI: 10.1111/bcp.12763 -
European Heart Journal Oct 2022Permanent transseptal left bundle branch area pacing (LBBAP) is a promising new pacing method for both bradyarrhythmia and heart failure indications. However, data... (Observational Study)
Observational Study
AIMS
Permanent transseptal left bundle branch area pacing (LBBAP) is a promising new pacing method for both bradyarrhythmia and heart failure indications. However, data regarding safety, feasibility and capture type are limited to relatively small, usually single centre studies. In this large multicentre international collaboration, outcomes of LBBAP were evaluated.
METHODS AND RESULTS
This is a registry-based observational study that included patients in whom LBBAP device implantation was attempted at 14 European centres, for any indication. The study comprised 2533 patients (mean age 73.9 years, female 57.6%, heart failure 27.5%). LBBAP lead implantation success rate for bradyarrhythmia and heart failure indications was 92.4% and 82.2%, respectively. The learning curve was steepest for the initial 110 cases and plateaued after 250 cases. Independent predictors of LBBAP lead implantation failure were heart failure, broad baseline QRS and left ventricular end-diastolic diameter. The predominant LBBAP capture type was left bundle fascicular capture (69.5%), followed by left ventricular septal capture (21.5%) and proximal left bundle branch capture (9%). Capture threshold (0.77 V) and sensing (10.6 mV) were stable during mean follow-up of 6.4 months. The complication rate was 11.7%. Complications specific to the ventricular transseptal route of the pacing lead occurred in 209 patients (8.3%).
CONCLUSIONS
LBBAP is feasible as a primary pacing technique for both bradyarrhythmia and heart failure indications. Success rate in heart failure patients and safety need to be improved. For wider use of LBBAP, randomized trials are necessary to assess clinical outcomes.
Topics: Humans; Female; Aged; Bundle of His; Cardiac Pacing, Artificial; Bundle-Branch Block; Bradycardia; Electrocardiography; Heart Failure; Treatment Outcome
PubMed: 35979843
DOI: 10.1093/eurheartj/ehac445 -
Southern Medical Journal Mar 2023Remdesivir, a viral RNA-dependent RNA polymerase inhibitor, found extensive use in coronavirus disease 2019-infected patients because it curbs the viral load expansion.... (Review)
Review
Remdesivir, a viral RNA-dependent RNA polymerase inhibitor, found extensive use in coronavirus disease 2019-infected patients because it curbs the viral load expansion. Among patients hospitalized as a result of lower respiratory tract infection, remdesivir proved to improve recovery time; however, remdesivir also can induce significant cytotoxic effects on cardiac myocytes. In this narrative review, we discuss the pathophysiological mechanism of remdesivir-induced bradycardia and diagnostic and management strategies for these patients. We conclude that further research is necessary to understand better the mechanism of bradycardia in coronavirus disease 2019 patients with or without cardiovascular disorder treated with remdesivir.
Topics: Humans; Bradycardia; COVID-19; COVID-19 Drug Treatment; Cardiovascular Diseases
PubMed: 36863055
DOI: 10.14423/SMJ.0000000000001519 -
The Journal of Emergency Medicine Aug 2020BRASH syndrome, or Bradycardia, Renal Failure, AV blockade, Shock, and Hyperkalemia, has recently become recognized as a collection of objective findings in a specific...
BACKGROUND
BRASH syndrome, or Bradycardia, Renal Failure, AV blockade, Shock, and Hyperkalemia, has recently become recognized as a collection of objective findings in a specific clinical context pertaining to emergency medicine and critical care. However, there is little emergency medicine and critical care literature specifically evaluating this condition.
OBJECTIVE
We sought to define and review BRASH syndrome and identify specific management techniques that differ from the syndromes as they present individually.
DISCUSSION
BRASH syndrome is initiated by synergistic bradycardia due to the combination of hyperkalemia and medications that block the atrioventricular (AV) node. The most common precipitant is hypovolemia or medications promoting hyperkalemia or renal injury. Left untreated, this may result in deteriorating renal function, worsening hyperkalemia, and hemodynamic instability. Patients can present with a variety of symptoms ranging from asymptomatic bradycardia to multiorgan failure. BRASH syndrome should be differentiated from isolated hyperkalemia and overdose of AV-nodal blocking medications. Treatment includes fluid resuscitation, hyperkalemia therapies (intravenous calcium, insulin/glucose, beta agonists, diuresis), management of bradycardia (which may necessitate epinephrine infusion), and more advanced therapies if needed (lipid emulsion, glucagon, or high-dose insulin infusion). Understanding and recognizing the pathophysiology of BRASH syndrome as a distinct entity may improve patient outcomes.
CONCLUSIONS
BRASH syndrome can be a difficult diagnosis and is due to a combination of hyperkalemia and medications that block the AV node. Knowledge of this condition may assist emergency and critical care providers.
Topics: Atrioventricular Block; Bradycardia; Electrocardiography; Humans; Hyperkalemia; Renal Insufficiency; Syndrome
PubMed: 32565167
DOI: 10.1016/j.jemermed.2020.05.001 -
The Primary Care Companion For CNS... Aug 2023
Topics: Humans; Bradycardia; Olanzapine
PubMed: 37595163
DOI: 10.4088/PCC.22cr03453 -
BMJ Case Reports Sep 2021Remdesivir is an antiviral used for the treatment of COVID-19 requiring hospitalisation. Information on its cardiovascular safety profile is scarce. We report the case...
Remdesivir is an antiviral used for the treatment of COVID-19 requiring hospitalisation. Information on its cardiovascular safety profile is scarce. We report the case of a 37-year-old man with COVID-19 who developed bradycardia after receiving remdesivir. We recommend a baseline ECG for all patients prior to receiving remdesivir and continuous cardiac monitoring during treatment, especially among those with underlying cardiovascular disease, elderly and using β-blockers.
Topics: Adenosine Monophosphate; Adult; Aged; Alanine; Antiviral Agents; Bradycardia; Humans; Male; SARS-CoV-2; COVID-19 Drug Treatment
PubMed: 34479903
DOI: 10.1136/bcr-2021-245289