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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 e407 CLINICAL STATEMENTS AND GUIDELINES

and beta-adrenergic stimulatory effects, including increasing chronotropy, inotropy, blood pressure, and myocardial oxygen consumption.S5.3.2.1-20 The standard dosage for advanced cardiac life support is 2 to 10 mcg/ min with titration to hemodynamic response.S5.3.2.1-13

Recommendation-Specific Supportive Text

1.	 In patients with sinus bradycardia, atropine at dosages of 0.5 to 2 mg usually enhances automaticity, but in rare cases can be associated with intra-atrial reentry and or sinus pauses.S5.3.2.1-21 The sinoatrial node response to atropine is bimodal, lower doses (usually <0.5 mg) are associated with slower rates and acceleration with higher doses.S5.3.2.1-15,S5.3.2.1-22,S5.3.2.1-23 One clinical trial,S5.3.2.1-1 a post hoc analysis of MI patients,S5.3.2.1-3 and 2 observational studiesS5.3.2.1-2,S5.3.2.1-4 have reported efficacy of atropine in the treatment of bradycardia. In patients with hemodynamically unstable sinus bradycardia and atrioventricular block, atropine has demonstrated some benefit and minimal risk of worsening bradycardia, ischemia or potentiating ventricular fibrillation.S5.3.2.1-1–S5.3.2.1-4 In an RCT of men undergoing elective laparoscopic prostate surgery, atropine effectively treated anesthetic induced sinus bradycardia.S5.3.2.1-24

2.	 There are numerous case reports and series describing the salutary use of isoproterenol in patients presenting with sinus bradycardia;S5.3.2.1-

5,S5.3.2.1-6,S5.3.2.1-9 however, there are no clinical

Table 8.  Acute Medical Management of Bradycardia Attributable to SND or Atrioventricular Block

Medication Dosage Comments Symptomatic sinus bradycardia or atrioventricular block Atropine 0.5–1 mg IV (may be repeated every 3–5 min to a maximum dose of 3 mg)S5.3.2.4-20–S5.3.2.4-24 Dopamine 5 to 20 mcg/kg/min IV, starting at 5 mcg/kg/min and increasing by 5 mcg/kg/min every 2 minS5.3.2.4-25 Dosages of >20 mcg/kg/min may result in vasoconstriction or arrhythmias Isoproterenol 20–60 mcg IV bolus followed doses of 10–20 mcg, or infusion of 1–20 mcg/min based on heart rate responseS5.3.2.4-26–S5.3.2.4-32 Monitor for potential development of ischemic chest pain Epinephrine 2–10 mcg/min IV or 0.1–0.5 mcg/kg/min IV titrated to desired effectS5.3.2.4-17,S5.3.2.4-31,S5.3.2.4-33 Second- or third-degree atrioventricular block associated with acute inferior MI Aminophylline 250-mg IV bolus Calcium channel blocker overdose 10% calcium chloride 1–2 g IV every 10–20 min or an infusion of 0.2–0.4 mL/kg/ hS5.3.2.4-34–S5.3.2.4-36 10% calcium gluconate 3–6 g IV every 10–20 min or an infusion at 0.6–1.2 mL/kg/ hS5.3.2.4-34–S5.3.2.4-36 Beta-blocker or calcium channel blocker overdose Glucagon 3–10 mg IV with infusion of 3–5 mg/hS5.3.2.4-37,S5.3.2.4-38 High dose insulin therapy IV bolus of 1 unit/kg followed by an infusion of 0.5 units/ kg/h.S5.3.2.4-36,S5.3.2.4-39,S5.3.2.4-40 Follow glucose and potassium levels Digoxin overdose Digoxin antibody fragment Dosage is dependent on amount ingested or known digoxin concentrationS5.3.2.4-41–S5.3.2.4-48 One vial binds approximately 0.5 mg of digoxin

Administer over at least 30 min May be repeated

Post-heart transplant Aminophylline 6 mg/kg in 100–200 mL of IV fluid over 20–30 min Theophylline 300 mg IV, followed by oral dose of 5–10 mg/kg/d titrated to effect Therapeutic serum levels range from 10–20 mcg/mL

Usual posttransplant dosages average 450 mg±100 mg/d

Spinal cord injury Aminophylline 6 mg/kg in 100–200 mL of IV fluid over 20–30 minS5.3.2.4-7 Theophylline Oral dose of 5–10 mg/kg/d titrated to effectS5.3.2.4-6 Effective dosages often result in serum levels below the usual effective range of 10–20 mcg/mL IV indicates intravenous; and MI, myocardial infarction.

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