1 · Is the patient unstable?
Bradycardia with hypotension, shock, acute altered mental status, ischemic chest discomfort, or acute heart failure requires emergency care. Activate EMS; do not send the patient home or have them drive to the hospital.
Provide assessment, monitoring, and support within your clinic’s capabilities while awaiting EMS. In a resuscitation setting, treatment may include atropine, transcutaneous pacing, or a dopamine/epinephrine infusion, with expert consultation and possible transvenous pacing.[2]
A reassuring blood pressure does not make dangerous AV block an outpatient problem.New Mobitz II, high-grade, or complete AV block needs urgent monitored evaluation, even when the patient reports few symptoms.[1]
2 · Identify the rhythm
Obtain a 12-lead EKG and compare prior tracings. Assess P waves, PR intervals, QRS width, and whether every atrial impulse conducts. Record the heart rate, blood pressure, symptoms, and any pauses.[3]
For 2:1 block, avoid assigning Mobitz I or II from that pattern alone. New or unexplained 2:1 block warrants prompt expert assessment; symptoms or concern for infranodal disease favor urgent monitored evaluation.[1]
3 · Review medications and reversible causes
Check the actual medication list, doses, recent changes, and possible duplicate therapy. Common contributors include beta blockers, diltiazem/verapamil, digoxin, and some antiarrhythmic drugs. Medication changes should consider why the drug was prescribed; significant block should not be managed simply by stopping a medicine and waiting.[1]
Renal dysfunction, medication accumulation, or electrolyte concern
Electrolytes and renal function; drug level when relevant, such as suspected digoxin toxicity.
Possible hypothyroidism
Thyroid testing when clinically indicated.
Snoring, witnessed apneas, or nocturnal bradycardia
Assess for sleep apnea; nocturnal bradycardia alone is not a pacemaker indication.
Chest pain, hypoxia, or acute systemic illness
Assess and treat the acute cause; escalate according to clinical status.
[1], [2], [3]
4 · Connect symptoms to the rhythm
Ask about syncope, near-syncope, fatigue, exercise intolerance, and symptom timing. Document whether symptoms occurred during bradycardia, after termination of a fast rhythm, or with activity.
If intermittent symptoms remain unexplained after the initial evaluation, choose ambulatory monitoring according to their frequency. Frequent symptoms may be captured with a short monitor; less frequent events require longer recording. EP may consider an implantable loop recorder for infrequent unexplained events.[3]
Monitoring helps stable patients establish a diagnosis.It does not replace urgent monitored evaluation for dangerous AV block or an unstable patient.
5 · Choose the referral pathway
Emergency / monitored evaluation
Instability, new Mobitz II, high-grade block, or complete AV block.
Expedited cardiology / EP
Symptomatic sinus node dysfunction, unexplained syncope with conduction disease, or concerning 2:1 block. Escalate to emergency care if current findings warrant it.
Planned follow-up
Selected stable, asymptomatic sinus bradycardia or uncomplicated first-degree/Mobitz I block, after medication and clinical review.
[1], [3]
Send the EKG, prior tracings, medication list, symptom timeline, and available monitoring/labs with the referral. Specialist evaluation can determine whether further testing or pacing is needed.
Clinical takeaway: Assess stability, identify the conduction pattern, review reversible contributors, and refer according to risk—not the pulse number alone.