Management of Exertional Symptoms in Patients with Bradycardia

Initial Assessment and Diagnostic Approach

The American College of Cardiology recommends that sinus bradycardia alone should not be used for the diagnosis of sinus node dysfunction; multiple factors must be considered for the individual patient 2
The American Heart Association suggests that bradycardia with a heart rate of 58 bpm is relatively mild and may be physiological, especially if the patient is physically active, however this fact is from a less preferred source 3
The key clinical question is whether the patient's exertional symptoms are related to the bradycardia or have another cause, according to the American College of Cardiology 1, 4
In patients with exertional symptoms who have bradycardia at rest, an exercise treadmill test is reasonable to determine whether they may benefit from permanent pacing (Class IIa recommendation, Level of Evidence: C-LD), as recommended by the American College of Cardiology and the American Heart Association 1, 4

Exercise testing can help establish if there is chronotropic incompetence, which represents failure to reach a target heart rate with exertion that is inadequate to meet metabolic demand, according to the American College of Cardiology 2
The American College of Cardiology recommends that permanent pacing is NOT indicated for asymptomatic sinus bradycardia 1, 4
Permanent pacing should be considered if exercise testing demonstrates chronotropic incompetence correlating with symptoms, according to the American College of Cardiology 4
The American College of Cardiology suggests that permanent pacing should also be considered if there is evidence of high-grade AV block during exercise, or if symptoms persist and are clearly attributable to bradycardia despite treatment of any underlying cause 1, 4

The American Heart Association notes that chest pain with exertion requires careful evaluation to rule out coronary artery disease, which becomes more prevalent in individuals over 35 years 5
The American College of Cardiology recommends that non-cardiac causes of chest pain and shortness of breath should also be considered, including pulmonary conditions like pneumothorax, however this fact is not directly cited 5