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Kusumoto et al 2018 Bradycardia Clinical Practice Guidelines

Circulation. 2019;140:e382–e482. DOI: 10.1161/CIR.0000000000000628 August 20, 2019 e383 CLINICAL STATEMENTS AND GUIDELINES

TABLE OF CONTENTS

Top 10 Take-Home Messages For the Management of Bradycardia and Cardiac Conduction Delay . . . . . . . . e384 Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e384 1.	Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e385 1.1.	 Methodology and Evidence Review . . . . . . . . . . e385 1.2.	 Organization of the Writing Committee . . . . . . e386 1.3.	 Document Review and Approval . . . . . . . . . . . . e386 1.4.	 Scope of the Guideline . . . . . . . . . . . . . . . . . . . e386 1.5.	 Class of Recommendation and Level of Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . e386 1.6.	 Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . e388 2.	Epidemiology and Definitions . . . . . . . . . . . . . . . . . . e388 2.1.	 Bradycardia and Conduction Disorders . . . . . . . e388 2.2.	 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . e388 3.	Clinical Manifestation of Bradycardia and Conduction Disorders . . . . . . . . . . . . . . . . . . . . e391 3.1.	 Clinical Manifestations of Bradycardia . . . . . . . . e391 3.2.	 Clinical Manifestations of Conduction Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e391 4.	General Evaluation of Patients With Documented or Suspected Bradycardia or Conduction Disorders . . . . . . . . . . . . . . . . . . . . . . e392 4.1.	 History and Physical Examination of Patients With Documented or Suspected Bradycardia or Conduction Disorders . . . . . . . . . . . . . . . . . . e392 4.2.	 Noninvasive Evaluation . . . . . . . . . . . . . . . . . . . e392 4.2.1.	Resting ECG in Patients With Documented or Suspected Bradycardia or Conduction Disorders . . . . . . . . . . . . e392 4.2.2.	Exercise Electrocardiographic Testing in Patients With Documented or Suspected Bradycardia or Conduction Disorders . . . e397 4.2.3.	Ambulatory Electrocardiography in Patients With Documented or Suspected Bradycardia or Conduction Disorders . . . . . . . . . . . . . . . . . . . . . . . . e397 4.2.4.	Imaging in Patients With Documented or Suspected Bradycardia or Conduction Disorders . . . . . . . . . . . . . . . . . . . . . . . . e399 4.2.5.	Laboratory Testing in Patients With Documented or Suspected Bradycardia or Conduction Disorders . . . . . . . . . . . . e400 4.2.6.	Genetic Testing in Patients With Documented or Suspected Bradycardia or Conduction Disorders . . . . . . . . . . . . e401 4.2.7.	Sleep Apnea Evaluation and Treatment in Patients With Documented or Suspected Bradycardia or Conduction Disorders . . . . . . . . . . . . . . . . . . . . . . . . e402 4.3.	 Invasive Testing . . . . . . . . . . . . . . . . . . . . . . . . . e403 4.3.1.	Implantable Cardiac Monitor in Patients With Documented or Suspected Bradycardia or Conduction Disorders . . . e403 4.3.2.	Electrophysiology Study in Patients With Documented or Suspected Bradycardia or Conduction Disorders . . . e404 5.	Bradycardia Attributable to SND . . . . . . . . . . . . . . . . e404 5.1.	 Pathology/Pathophysiology/Etiology of SND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e404 5.2.	 Clinical Presentation of SND . . . . . . . . . . . . . . . e405 5.3.	 Acute Management of SND . . . . . . . . . . . . . . . e405 5.3.1.	Acute Management of Reversible Causes of SND . . . . . . . . . . . . . . . . . . . . e405 5.3.2.	Acute Medical Therapy for Bradycardia . . . . . . . . . . . . . . . . . . . . . . e406 5.3.3.	Temporary Pacing for Bradycardia Attributable to SND . . . . . . . . . . . . . . . . e410 5.4.	 Chronic Therapy/Management of Bradycardia Attributable to SND . . . . . . . . . . . . . . . . . . . . . e412 5.4.1.	General Principles of Chronic Therapy/Management of Bradycardia Attributable to SND . . . . . . . . . . . . . . . . e412 5.4.2.	Transient/Reversible Causes (Including Medications) of Bradycardia Attributable to SND . . . . . . . . . . . . . . . . e413 5.4.3.	Additional Testing of Bradycardia Attributable to SND . . . . . . . . . . . . . . . . e413 5.4.4.	Permanent Pacing for Chronic Therapy/Management of Bradycardia Attributable to SND . . . . . . . . . . . . . . . . e414 6.	Bradycardia Attributable to Atrioventricular Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e417 6.1.	 Pathophysiology, Etiology, and Classification of Bradycardia Attributable to Atrioventricular Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e417 6.2.	 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . e419 6.3.	 Acute Management . . . . . . . . . . . . . . . . . . . . . e419 6.3.1.	Acute Management of Reversible Causes of Bradycardia Attributable to Atrioventricular Block . . . . . . . . . . . . . e419 6.3.2.	Acute Medical Therapy for Bradycardia Attributable to Atrioventricular Block . . . . . . . . . . . . . . . . . . . . . . . . . . . e420 6.3.3.	Temporary Pacing for Atrioventricular Block . . . . . . . . . . . . . . . . . . . . . . . . . . . e421 6.4.	 Chronic Therapy/Management of Bradycardia Attributable to Atrioventricular Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e422 6.4.1.	General Principles of Chronic Therapy/ Management of Bradycardia Attributable to Atrioventricular Block . . . e424 6.4.2.	Transient/Potentially Reversible Causes of Atrioventricular Block . . . . . . . e424 6.4.3.	Additional Testing for Chronic Therapy/Management of Bradycardia Attributable to Atrioventricular Block . . . e426 6.4.4.	Permanent Pacing . . . . . . . . . . . . . . . . . e427 7.	Conduction Disorders (With 1:1 Atrioventricular Conduction) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e432 7.1.	 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . e432 7.2.	 Etiology/Classification . . . . . . . . . . . . . . . . . . . . e432 7.3.	 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . e432 7.4.	 Evaluation of Conduction Disorders . . . . . . . . . e433 7.5.	 Management of Conduction Disorders (With 1:1 Atrioventricular Conduction) . . . . . . . e434 8.	Special Populations . . . . . . . . . . . . . . . . . . . . . . . . . . e436 8.1.	 Perioperative Management . . . . . . . . . . . . . . . . e436 8.1.1.	Patients at Risk for Bradycardia During Noncardiac Surgery or Procedures . . . . . . . . . . . . . . . . . . . . . . . e436

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