Bradycardia Treatment Guidelines

First-Line Pharmacologic Management

The American College of Cardiology recommends atropine 0.5-1 mg IV as the initial treatment for symptomatic bradycardia with hemodynamic compromise, repeatable every 3-5 minutes up to a maximum of 3 mg, with a Class IIa recommendation and C-LD level of evidence 1, 2, 3
Atropine has a Class IIa recommendation (reasonable to use) with C-LD level of evidence for the treatment of symptomatic bradycardia with hemodynamic compromise 1, 4

Dopamine 5-20 mcg/kg/min IV, starting at 5 mcg/kg/min and increasing by 5 mcg/kg/min every 2 minutes, may be considered in patients at low risk for coronary ischemia, with a Class IIb recommendation 1, 2, 3
Isoproterenol 20-60 mcg IV bolus or 1-20 mcg/min infusion based on heart rate response, may be considered in patients at low risk for coronary ischemia, with a Class IIb recommendation 1, 2
Epinephrine 2-10 mcg/min IV or 0.1-0.5 mcg/kg/min IV titrated to effect, may be considered in patients at low risk for coronary ischemia, with a Class IIb recommendation 1, 2, 3

The American College of Cardiology recommends avoiding isoproterenol in patients with suspected coronary ischemia, as it increases myocardial oxygen demand and decreases coronary perfusion 2, 5
Atropine is contraindicated (Class III: Harm) in heart transplant patients without autonomic reinnervation, and alternative treatments such as aminophylline 6 mg/kg in 100-200 mL IV over 20-30 minutes may be considered 1, 5, 3
Bradycardia from spinal cord injury may be refractory to atropine and adrenergic drugs, and treatment with aminophylline or theophylline may be beneficial 4, 6, 7

Temporary pacing is reasonable when bradycardia remains hemodynamically unstable despite medical therapy, with transvenous pacing being a Class IIa recommendation and transcutaneous pacing being a Class IIb recommendation 4, 6, 7

For beta-blocker or calcium channel blocker overdose causing bradycardia, treatment with calcium 1-2 g calcium chloride 10% IV every 10-20 minutes, glucagon 3-10 mg IV with infusion of 3-5 mg/h, or high-dose insulin 1 unit/kg IV bolus followed by 0.5 units/kg/h infusion may be considered, with a Class IIa recommendation 1, 2, 3