Management of Bradycardia in Patients with Uremia

The American College of Cardiology recommends evaluating patients with uremia for signs and symptoms of poor perfusion associated with bradycardia, including altered mental status, ischemic chest discomfort, acute heart failure, hypotension, or shock 2
A 12-lead ECG should be obtained to confirm bradycardia and assess for signs of hyperkalemia, which is common in uremic patients 3, 2
The European Heart Journal suggests checking magnesium levels, as hypomagnesemia can contribute to bradycardia 4

Management Algorithm for Bradycardia in Uremic Patients

The American College of Cardiology recommends treating hyperkalemia aggressively if present, and considering sodium bicarbonate if metabolic acidosis is present 1
The European Heart Journal suggests correcting other electrolyte imbalances, such as hypomagnesemia and hypocalcemia 4

The American College of Cardiology recommends administering atropine 0.5 mg IV every 3-5 minutes to a maximum total dose of 3 mg for symptomatic bradycardia 2
The American College of Cardiology also suggests initiating IV infusion of β-adrenergic agonists, such as dopamine or epinephrine, if bradycardia persists despite atropine 2

Temporary pacing, such as transcutaneous pacing, should be considered for unstable patients who don't respond to pharmacologic therapy 2

Medication doses may need adjustment in renal failure, particularly those that are renally cleared, as recommended by the American College of Cardiology 1

The American College of Cardiology recommends evaluating for permanent pacing only if bradycardia persists despite correction of uremia and electrolyte abnormalities 5, 1
The American College of Cardiology also suggests considering discontinuation or dose reduction of medications that may contribute to bradycardia, such as beta-blockers, calcium channel blockers, and digoxin 1