Initial Workup for Bradycardia

History and Physical Examination

The American College of Cardiology recommends obtaining detailed information about symptoms including frequency, timing, duration, severity, circumstances, triggers, and alleviating factors in patients with bradycardia 1
A thorough review of all prescription and over-the-counter medications is necessary, as many commonly prescribed medications can elicit or exacerbate bradyarrhythmias, according to the American College of Cardiology 1, 3
The physical examination should evaluate for signs of bradycardia and underlying structural heart disease, as recommended by the American College of Cardiology 1

The American College of Cardiology suggests that a 12-lead ECG should be performed to document rhythm, rate, conduction abnormalities, and screen for structural heart disease or systemic illness in patients with bradycardia 2, 4
Initial vital signs, including blood pressure and oxygen saturation, should be obtained, and IV access should be established for potential medication administration, as recommended by the American Heart Association 5, 6
Cardiac rhythm monitoring should be used to establish correlation between heart rate/conduction abnormalities and symptoms, with the specific type of monitor chosen based on frequency and nature of symptoms, according to the American College of Cardiology 7
Laboratory testing, such as thyroid function tests and Lyme titer, should be directed toward suspected specific diagnoses, as recommended by the American College of Cardiology 8

Exercise electrocardiographic testing is reasonable for patients with suspected chronotropic incompetence, exercise-related symptoms suspicious for bradycardia or conduction disorders, or 2:1 atrioventricular block of unknown level, according to the American Heart Association 9
Genetic testing should be considered in patients with a family history of inherited conduction disease or first-degree relatives of patients in whom a conduction disorder-causative mutation has been identified, as recommended by the American College of Cardiology 8

The American Heart Association recommends assessing if bradycardia is appropriate for clinical condition, determining if the patient is symptomatic, and evaluating for signs of poor perfusion or shock in patients with bradycardia 5, 6
Identifying and treating potentially reversible causes, such as hypothyroidism and infectious causes, is crucial in managing bradycardia, according to the American College of Cardiology 8

The American College of Cardiology advises against relying solely on the initial ECG for diagnosis, as it provides a rhythm correlation with symptoms in only approximately 5% of patients with syncope 2
Asymptomatic or minimally symptomatic patients should not be treated unless there is suspicion that the rhythm is likely to progress or become life-threatening, according to the American Heart Association 5, 6