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cardio.brady_tachy_syndrome.v1

Brady-tachy syndrome / sick sinus syndrome

cardiologychronicacuteadultgeriatricoutpatientacuteinpatienttransition
Start encounter →Print handoutPRODUCTION

Brady-tachy / SND — PPM (DDDR) cornerstone for symptomatic SND; AAD usually requires PPM in place first. Anticoagulation per CHA2DS2-VASc when AF burden documented (subclinical AF ≥6 min/24 h ASSERT). Reversible cause review (drugs, hypothyroid, OSA, electrolyte, ischemia) before PPM commitment. Open: manifest, atoms, problem-package, RxCUI verification, engine-specific tests; SND-specific calculator gap.

Entry points (5)

  • symptom
    Unexplained syncope or near-syncope (ACC/AHA/HRS 2018 Class I evaluation)
    syncope_unexplained
  • symptom
    Chronic fatigue / exercise intolerance (ACC/AHA/HRS 2018 SND symptom criteria)
    fatigue_exercise_intolerance
  • symptom
    Palpitations alternating with brady episodes (ACC/AHA/HRS 2018 tachy-brady definition)
    palpitations_with_brady_episodes
  • imaging
    Documented sinus brady, sinus pauses, or chronotropic incompetence (ACC/AHA/HRS 2018 Kusumoto)
    documented_brady_or_pauses
  • history
    AF with prolonged conversion pauses (ACC/AHA/HRS 2018 Section 4.1)
    prior_AF_with_long_pauses_after_conversion

Required inputs (14)

  • agerequired
    demographic • used at CONTEXT
    Pacemaker indication; reversibility (ACC/AHA/HRS 2018 Section 4)
  • hrrequired
    vital • used at CONTEXT
    Brady severity; chronotropic response (ACC/AHA/HRS 2018 Kusumoto)
  • sbprequired
    vital • used at RED_FLAGS
    Hemodynamic stability (ACLS 2020 bradycardia algorithm)
  • tshrequired
    lab • used at INITIAL_WORKUP
    Hypothyroid reversible cause (ACC/AHA/HRS 2018 Section 4.1.1 reversible causes)
  • bmp_mg_krequired
    lab • used at INITIAL_WORKUP
    Electrolyte reversible cause; AAD safety (ACC/AHA/HRS 2018)
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    DOAC + AAD dosing (ACC/AHA/HRS 2023 AF guideline renal-adjusted dosing)
  • troponin
    lab • used at INITIAL_WORKUP
    Ischemic SND — inferior MI (ACC/AHA/HRS 2018 Section 4.1.1)
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    Brady, pauses, AV conduction, P-wave morphology (ACC/AHA/HRS 2018 Class I)
  • holter_or_loop_recorderrequired
    imaging • used at INITIAL_WORKUP
    Symptom-rhythm correlation; pause documentation (ACC/AHA/HRS 2018 Class I ambulatory monitoring)
  • tterequired
    imaging • used at INITIAL_WORKUP
    Structural disease; EF (ACC/AHA/HRS 2018 Section 4)
  • rate_lowering_meds_reviewrequired
    history • used at CONTEXT
    BB / non-DHP CCB / digoxin / ivabradine / donepezil / lithium / amiodarone (ACC/AHA/HRS 2018 reversible-cause checklist)
  • cha2ds2_vasc_factorsrequired
    history • used at RISK_STRATIFICATION
    AC indication if AF burden (ACC/AHA/HRS 2023 AF guideline CHA2DS2-VASc)
  • prior_MI_or_CADrequired
    history • used at CONTEXT
    Ischemic SND (ACC/AHA/HRS 2018 Section 4.1.1)
  • current_medsrequired
    medication • used at CONTEXT
    Adjust AVN-blockers (ACC/AHA/HRS 2018 drug-induced SND)

12-phase flow (12)

  1. 1FRAME
    Confirm SND with documented brady + symptom correlation; rule out reversible causes — drug, hypothyroid, OSA, electrolyte, ischemia, infiltrative (ACC/AHA/HRS 2018 Section 4.1 Kusumoto; ESC 2021 pacing Section 5)
    inputs: ecg_12_lead, holter_or_loop_recorder
    advance: SND confirmed and reversible causes addressed
  2. 2ENTRY
    Syncope / presyncope / fatigue / palpitations alternating with brady (ACC/AHA/HRS 2018 SND symptom criteria)
    inputs: age
    advance: Engine entered
  3. 3CONTEXT
    Med review — BB, non-DHP CCB, digoxin, donepezil, ivabradine; comorbidities; prior MI (ACC/AHA/HRS 2018 reversible-cause checklist)
    inputs: rate_lowering_meds_review, cha2ds2_vasc_factors, prior_MI_or_CAD, current_meds
    advance: Context complete
  4. 4RED_FLAGS
    Syncope with documented pause >3 s; hemodynamic instability; AMS (ACC/AHA/HRS 2018 Class I pacing indication; ACLS 2020 bradycardia algorithm)
    inputs: sbp, hr
    actions: bradycardia
    advance: Stable or pacing initiated
  5. 5INITIAL_WORKUP
    12-lead ECG, 24–48 h Holter or extended monitor (ILR if intermittent), TTE, TSH, BMP, K/Mg, creatinine, troponin if ischemia suspicion (ACC/AHA/HRS 2018 Section 4.1)
    inputs: ecg_12_lead, holter_or_loop_recorder, tte, tsh, bmp_mg_k, creatinine_egfr
    actions: panel.cardiac, panel.thyroid, panel.renal
    advance: Documentation complete
  6. 6BRANCHING_WORKUP
    Stress test for chronotropic incompetence (ACC/AHA/HRS 2018 Class IIa); sleep study; tilt table for vasovagal overlap; cardiac MRI for infiltrative (ESC 2021 pacing)
    advance: Branch resolved
  7. 7DIFFERENTIAL
    SND vs AV block vs vagally mediated vs drug-induced vs ischemic vs infiltrative (ACC/AHA/HRS 2018 Section 4 differential)
    advance: Diagnosis confirmed
  8. 8RISK_STRATIFICATION
    Symptom-rhythm correlation; CHA2DS2-VASc + HAS-BLED for AF burden (ACC/AHA/HRS 2023 AF); pacemaker indication (ACC/AHA/HRS 2018)
    inputs: cha2ds2_vasc_factors
    actions: calc.cha2ds2vasc, calc.has_bled
    advance: Indications documented
  9. 9TREATMENT
    Reverse drugs/causes first (ACC/AHA/HRS 2018 Class I); permanent pacemaker DDDR with rate response per MOST (Lamas NEJM 2002 PMID 12087119) / DANPACE (Nielsen Circulation 2011); cautious AAD only after PPM if AF burden; AC per CHA2DS2-VASc (ACC/AHA/HRS 2023 AF)
    inputs: hr
    advance: Plan documented
  10. 10DISPOSITION
    Admit if syncope with pause / hemodynamic instability / pacemaker procedure planned; outpatient EP referral otherwise (ACC/AHA/HRS 2018 Section 4.1)
    advance: Disposition documented
  11. 11MONITORING
    Pacemaker interrogation; AF burden; symptom diary (ESC 2021 pacing Section 7 remote monitoring; ACC/AHA/HRS 2018)
    advance: Monitoring scheduled
  12. 12FOLLOWUP
    EP q3–6 mo; PPM check; AC review; lifestyle — OSA management, exercise (ACC/AHA/HRS 2018; ESC 2021 pacing follow-up)
    advance: Follow-up booked