Bradycardia

Definition
Your heart normally beats between 60 and 100 times a minute to provide enough
oxygen-carrying blood to your body. A heart rate below 60 beats a minute is called
bradycardia.

Although a heart rate this slow can be normal during sleep or in a well-trained athlete,
bradycardia signals a problem if you have signs and symptoms such as fainting or
shortness of breath.

Symptoms
Many people with mild bradycardia have no symptoms, especially if their heart rate is
between 50 and 60 beats a minute. When your heart beats fewer than 50 times a
minute, it may not supply enough blood to your organs and tissues. This can cause:

 Near-fainting or fainting (syncope)

 Dizziness
 Weakness
 Fatigue
 Shortness of breath
 Chest pains
 Disturbed sleep
 Confusion
 Heart palpitations

Causes
Normal heartbeat
Your heart is a muscular pump that circulates blood throughout your body. There are
four hollow chambers in your heart — the two upper chambers are the atria, and the
lower, more muscular chambers are the ventricles. Each normal heartbeat begins in
the right atrium. There, the heart's natural pacemaker, called the sinus node, sends an
electrical signal that causes the atria to contract, filling the ventricles with blood. A
split second later, the electrical impulse travels across the atrioventricular (AV) node
into the ventricles. This makes both ventricles contract, sending blood to the lungs
and throughout the body.

Bradycardia
When you have bradycardia, either your heart's natural pacemaker isn't working
properly, or passage of the electrical signal is disrupted elsewhere in the electrical
system, causing an abnormally slow heart rhythm.

The most common type of bradycardia involves the sinus node. When the sinus node
is dysfunctional, it's often called sick sinus syndrome. Other times, a second pacing
node called the atrioventricular node or AV node malfunctions.

Sinus node malfunction. When the sinus node malfunctions, it may be called sick
sinus syndrome. Rhythm problems can occur if the signals through the sinus node are
blocked (sinoatrial node block), the sinus node pauses or temporarily stops, or signals
alternate fast and slow (tachycardia-bradycardia syndrome).

AV node malfunction. The atrioventricular (AV) node is the electrical hub

connecting the sinus node to the ventricles. When the conduction of electrical signals
through the AV node is disrupted, bradycardia or other heart rhythm disturbances can
develop. AV node malfunction (sometimes called heart block) is common in people
with heart disease, but it can also be caused by medications and other medical
conditions. There are several types of AV node block, depending on how many
electrical signals get through the AV node to the ventricles:
  First degree heart block. In the mildest form of heart block, all electrical signals from the
atria pass through the AV node more slowly than normal.
 Second degree heart block. In second degree heart block, not all electrical signals reach the
ventricles — some beats are "dropped" by the AV node.
 Third degree (complete) heart block. In third degree heart block, none of the electrical
impulses from the atria reach the ventricles. When this happens, the ventricles' backup
pacemaker is activated in order to pump blood to the body. However, the ventricular
pacemaker's rhythm is very slow and it isn't coordinated with the atrial signals. This type of
heart block can lead to ventricular tachycardia or ventricular fibrillation, dangerous rapid
heart rates that can cause sudden cardiac death.
 Bundle branch block. Further down the electrical pathway from the AV node, electrical
signals branch off through two bundles of nerve tissue called the right and left bundle
branches. In bundle branch block, the impulses are slowed or blocked when traveling
through the bundle branch to the ventricles. The overall heart rate may be normal, but
some people with bundle branch block may develop bradycardia.

When a slow heart rate is normal

Often, well-trained athletes have resting heart rates lower than 60 beats a minute.
Through regular workouts, their hearts have become highly efficient — able to
circulate adequate blood to the body using fewer beats. Also, a slower heart rate and
rhythm pauses are common during sleep in normal adults and children.

Risk factors
Several diseases and conditions can increase your risk of developing bradycardia,
including:

 Underactive thyroid (hypothyroidism). When your thyroid gland releases

too few hormones, it can slow your metabolism and cause bradycardia.
 Heart disease. When the heart has been damaged by cardiovascular disease
such as a heart attack, it can disrupt the heart's electrical system. In addition,
some common medications for high blood pressure and other heart problems
can cause bradycardia or make it worse.
 Electrolyte disorders. When your body's stores of calcium, potassium,
chloride or sodium are imbalanced, it can cause the heart muscle to beat
irregularly or too slowly.
 Older age. Aging-related damage to the heart muscle, as well as loss of the
cells responsible for transmitting electrical signals, can contribute to
bradycardia.
 Medications. Many common medications for heart disease and high blood
pressure are designed to slow the heart rate to help it beat more efficiently.
But, sometimes your medications may need to be adjusted if your heart rate is
too slow.

When to seek medical advice

You can have bradycardia and not know it — most people don't have symptoms until
their heart rate drops below 50 beats a minute.

You can check your heart rate by measuring your pulse at your wrist (radial artery) or
neck (carotid artery), counting the number of beats in one minute. Ideally, have a
nurse or doctor make sure you're checking your pulse correctly. If you have certain
abnormal heart rhythms, such as atrial fibrillation, the count that you get at your wrist
or neck may not be accurate.

If your heart rate is slow and you're experiencing dizziness, weakness, lack of energy
or fainting spells, call your health care provider for an evaluation.

Tests and diagnosis

In addition to a slower pulse and low blood pressure, a physical examination by your
doctor also may reveal a rhythm that alternates between slow and fast. For treatment
purposes, it's important for your doctor to pinpoint what is causing your bradycardia.
Diagnostic tests to determine the location and type of bradycardia include:

 Electrocardiogram (ECG). Sensor pads with wires attached, called

electrodes, are placed on your chest and sometimes limbs to measure your
heart's electrical impulses. Your heart's beating pattern can offer clues to the
type of bradycardia you have.
 Event monitor. An event monitor can help doctors evaluate more sporadic
bradycardia. You wear this portable ECG device at home and activate it when
you're experiencing symptoms. Your doctor can later evaluate the ECG strip
to determine if there's an association between your symptoms and your heart's
rhythm.
 Screening for underlying disorders. Blood or other tests may be done to
look for underlying conditions (such as thyroid or electrolyte problems) that
may be causing heart rhythm disturbances.

Complications
Complications of bradycardia include:

 Fainting. This is the most common complication of bradycardia. Many people

who experience fainting with bradycardia benefit from an implantable
pacemaker to regulate the heart's rhythm.
 Heart failure. Some people with long-standing bradycardia may develop
symptoms of heart failure because the heart isn't efficiently pumping blood to
the body.
 Dangerous arrhythmias. If you have third-degree heart block, it can lead to
ventricular tachycardia (very rapid heartbeat) or ventricular fibrillation (heart
muscle quivers and can't pump blood). These dangerous arrhythmias can cause
sudden cardiac death.

Treatments and drugs

Treatment for bradycardia depends on the cause and your symptoms. If you don't
have symptoms, treatment may involve simply monitoring of your heart over time. If
you have symptoms, treatment may involve identifying and controlling an underlying
condition, implanting a pacemaker, or adjusting medications.
Monitoring
If you don't have symptoms, you may not need treatment for your bradycardia. Your
doctor may want to monitor your condition periodically with electrocardiogram to
make sure the rhythm isn't changing.

Medications
Many common medications for heart disease and high blood pressure, such as beta
blockers, calcium channel blockers and anti-arrhythmics, can cause bradycardia. In
fact, the goal of some of these medications is to slow the heart's rhythm, which can be
helpful in conditions such as coronary artery disease. If you have symptoms from
bradycardia, your doctor may recommend decreasing or discontinuing these
medications or finding an alternative medication that doesn't affect your heart rate.

Sometimes, a person with bradycardia also has episodes of atrial fibrillation, when the
atria generate very rapid and irregular heartbeats. Irregular, rapid heartbeats can
dislodge a blood clot in the heart and cause a heart attack or stroke. If you have atrial
fibrillation, your doctor may prescribe warfarin or another blood thinner to help
reduce the risk of blood clots.

If you have tachycardia-bradycardia syndrome, you'll need treatment for both the
rapid and the slow rates. Your doctor may prescribe beta blockers or anti-arrhythmic
medications for the tachycardia — but because these medications can make
bradycardia worse, you may also need an implanted pacemaker to regulate your
heartbeat.

Pacemaker
Implanting a pacemaker is the most common treatment for bradycardia that causes
symptoms such as fainting. A pacemaker is a wallet-sized device with wires and
electrodes attached. The electrodes are threaded through your veins and into your
heart. The pacemaker device is implanted under your collarbone. The pacemaker
generates electrical impulses through the electrodes to regulate your heartbeat.

Depending on your condition, your doctor may recommend a dual-chamber

pacemaker. While a traditional pacemaker only stimulates the ventricles, or less
commonly the atria, a dual-chamber device has electrodes in both the atria and the
ventricles. Some pacemakers even have three leads, one for the right atrium and one
for each ventricle (biventricular pacemaker). Biventricular pacemakers are most
commonly used in individuals who have heart failure.

Treating underlying disorders

Several diseases and disorders can cause bradycardia, including thyroid disease, sleep
apnea, electrolyte disorders and others. Treating an underlying condition may be all
you need to resolve your bradycardia.

Prevention
Having heart disease dramatically increases your chances of developing a heart
arrhythmia, including bradycardia. Reduce this risk by taking steps to prevent heart
disease. If you already have heart disease, monitor it and follow your treatment plan
to lower your bradycardia risk.

To treat or eliminate risk factors that may lead to heart disease, follow these tips:

 Exercise and eat a healthy diet. Live a heart-healthy lifestyle by exercising

regularly and eating a healthy, low-fat diet that's rich in fruits, vegetables,
whole grains and antioxidants.
 Maintain a healthy weight. Obesity puts you at higher risk of developing
heart disease and bradycardias.
 Stop smoking. Tobacco use increases your risk of cardiovascular disease and
heart arrhythmias.
 Control stress. Avoid unnecessary stress and learn coping techniques to
handle normal stress in a healthy way.
 Go to checkups. Have regular physical exams and report any signs or
symptoms to your doctor.