Basic calculations
Bradycardia with a pulse
Follows the AHA 2025 and ERC 2025 adult bradycardia algorithms. Adverse features (shock, syncope, ischaemia, heart failure, altered mental status) call for atropine, then epinephrine, dopamine or isoprenaline infusion, or transcutaneous pacing. A risk of asystole (recent asystole, Mobitz II, complete heart block with broad QRS, pauses over 3 s) calls for transvenous pacing. It flags when atropine should be avoided (heart transplant, spinal cord injury) and gives specific treatment for beta-blocker, calcium-channel blocker and digoxin toxicity, hyperkalaemia and inferior MI.
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Guideline
Heart rate
Bradycardia: HR < 50 bpm (AHA) or < 60 bpm, with a pulse
Adverse features
Is the bradycardia causing them?
Risk of asystole
Context
Drug toxicity
Bradycardia with a pulse · AHA 2025
Brady
No adverse features
Monitor and treat the cause
- Assess with ABCDEIAHA 2025Oxygen if SpO₂ is low, IV access, 12-lead ECG, monitor; look for reversible causes (ischaemia, drugs, hyperkalaemia, hypothyroidism, raised intracranial pressure).
- Stable: observe and treat the causeAHA 2025No adverse features and no risk of asystole. Monitor, and refer for permanent pacing assessment if the cause is not reversible.
References
- American Heart Association. 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 9: Adult advanced life support. Circulation 2025;152(suppl 2).
- European Resuscitation Council Guidelines 2025: Adult advanced life support. Resuscitation 2025.
- Glikson M, et al. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J 2021;42:3427-3520.
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