Bradyarrhythmias.

In our opinion, the term bradyarrhythmia should be reserved for bradycardias (heart rates less than 60) that are associated with symptoms such as syncope or near-syncope, congestive heart failure, exercise intolerance, fatigue, or a confusional state that improves with resolution of the bradycardia. The mere presence of a bradycardia that is not associated with these symptoms almost never justifies aggressive intervention, with few notable exceptions. It is important to determine if the bradyarrhythmia will not resolve spontaneously or with the alleviation of a condition that is the likely cause of the bradyarrhythmia. If a hemodynamically stable patient can be observed safely while being treated for a metabolic or ischemic condition or an adverse drug reaction, then it is not justified to implant a permanent pacemaker, though a temporary pacemaker may be necessary in the interim. Certain forms of reflex-mediated syncope have an element of inappropriate bradycardia that may be amenable to pacing. Pacemaker implantation should be considered for patients with recurrent vasovagal or situational syncope that is refractory to other therapies. The treatment of specific bradyarrhythmias should be in accordance with the guidelines laid forth by the joint councils of the American Heart Association and the American College of Cardiology.