Intended for healthcare professionals

Practice Clinical updates

Bradyarrhythmias and pacemakers

BMJ 2018; 360 doi: (Published 15 March 2018) Cite this as: BMJ 2018;360:k642
  1. S Honarbakhsh, cardiology and electrophysiology registrar1,
  2. L Hunter, general practitioner2,
  3. A Chow, consultant cardiologist and electrophysiologist1,
  4. Ross J Hunter, consultant cardiologist and electrophysiologist1
  1. 1Department of Arrhythmia Services, Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, London EC1A 7BE, UK
  2. 2Rosemead Surgery, 8 Ray Park Avenue, Maidenhead SL6 8DS, UK
  1. Corresponding author: R J Hunter ross.hunter{at}

What you need to know

  • Suspect bradyarrhythmia in patients with symptoms of fainting, shortness of breath, chest pain, or lethargy, and a heart rate <60 beats/min on examination

  • Request 12-lead electrocardiography (ECG) to detect conduction abnormalities such as atrioventricular block or sinus node disease, and blood tests to exclude thyroid disorder and electrolyte imbalance

  • Referral to a cardiologist is usually needed to evaluate heart function and for management

  • Pacemaker implantation is indicated when symptoms can be attributed to bradycardia or atrioventricular block, or in asymptomatic patients with type 2 second-degree heart block or complete heart block

  • Complex devices such as biventricular pacemakers and implantable cardioverter defibrillators are being considered in patients with a pacing indication and left ventricular impairment to prevent worsening left ventricular function or sudden cardiac death

Bradyarrhythmias are heart rhythms with a rate of <60 beats/min, commonly due to conduction abnormalities in the heart such as sinus node disease or atrioventricular block.1 There is increased risk of sudden cardiac death due to slowing or stopping of the heart, and of falls, especially in older people, due to fainting.

Worldwide over one million pacemakers are implanted annually for bradyarrhythmias.23 With an ageing population this is expected to increase.4 New technologies such as leadless pacemakers are being introduced, which general physicians will increasingly encounter. This update will help physicians identify and manage bradyarrhythmias appropriately and will familiarise them with an increasingly complex array of pacemakers.

Fig 1

Position of sinus and atrioventricular nodes in the heart, with ECG features and causes of sinus node disease, first degree heart block, and atrioventricular node disease are described.

Sources and selection criteria

We used the 2016 European Society of Cardiology (ESC) heart failure guidelines,29 the 2013 ESC13 and 2012 American College of Cardiology Foundation (ACCF)/American Heart Association (AHA)/Heart Rhythm Society (HRS) pacing guidelines16 and the 2014 National Institute …

View Full Text

Log in

Log in through your institution


* For online subscription