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cardio.brady_tachy_syndrome.v1PRODUCTION
cardio.brady_tachy_syndrome.v1

Brady-tachy syndrome / sick sinus syndrome

cardiologychronicacuteadultgeriatric
Hard-required inputs
0 / 13
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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
2
Actions
0
Advance rule
Set
Advance when

SND confirmed and reversible causes addressed

Patient inputs (14)

Pacemaker indication; reversibility (ACC/AHA/HRS 2018 Section 4)

Brady severity; chronotropic response (ACC/AHA/HRS 2018 Kusumoto)

BB / non-DHP CCB / digoxin / ivabradine / donepezil / lithium / amiodarone (ACC/AHA/HRS 2018 reversible-cause checklist)

Ischemic SND (ACC/AHA/HRS 2018 Section 4.1.1)

Adjust AVN-blockers (ACC/AHA/HRS 2018 drug-induced SND)

Hypothyroid reversible cause (ACC/AHA/HRS 2018 Section 4.1.1 reversible causes)

Electrolyte reversible cause; AAD safety (ACC/AHA/HRS 2018)

DOAC + AAD dosing (ACC/AHA/HRS 2023 AF guideline renal-adjusted dosing)

Brady, pauses, AV conduction, P-wave morphology (ACC/AHA/HRS 2018 Class I)

Symptom-rhythm correlation; pause documentation (ACC/AHA/HRS 2018 Class I ambulatory monitoring)

Structural disease; EF (ACC/AHA/HRS 2018 Section 4)

Hemodynamic stability (ACLS 2020 bradycardia algorithm)

AC indication if AF burden (ACC/AHA/HRS 2023 AF guideline CHA2DS2-VASc)

Ischemic SND — inferior MI (ACC/AHA/HRS 2018 Section 4.1.1)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateninghemodynamic_instability_brady
    SBP <90 with HR <50 and signs of shock
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresyncope_with_documented_pause_gt_3s
    Syncope with documented sinus pause >3 s on monitor
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretachy_brady_after_AF_conversion
    Pause >3 s after spontaneous AF conversion
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereAAD_induced_brady_in_SND_without_PPM
    New brady or pauses on amiodarone / sotalol / flecainide before PPM
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatereversible_drug_induced_brady
    Brady on BB / non-DHP CCB / digoxin / donepezil / ivabradine / lithium
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatechronotropic_incompetence_on_stress
    Failure to reach 80% age-predicted HR on exercise stress
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehigh_AF_burden_post_PPM
    Device-detected AF burden ≥6 min in 24 h
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives risk stratification
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Recommended regimen

Acute brady management before / pending pacemaker
axis: sss_acute_brady_management
Selected axis "Acute brady management before / pending pacemaker" by default fallback (first axis)
  • atropine
    first line
    antimuscarinic
    0.5 mg IV q3–5 min, max 3 mg • IV • q3–5 min
    triggers: symptomatic_brady, pre_pacing
    ACLS 2020 bradycardia algorithm first-line; less effective in infranodal block (ACC/AHA/HRS 2018 Kusumoto)
    rxcui 1223
  • isoproterenol
    second line
    beta_agonist
    2–10 mcg/min • IV • continuous
    triggers: atropine_unresponsive, pacing_unavailable
    β1/β2 agonist increases SA rate; bridge to pacing (ACLS 2020; ACC/AHA/HRS 2018)
    rxcui 6054
  • epinephrine
    second line
    sympathomimetic
    2–10 mcg/min • IV • continuous
    triggers: atropine_unresponsive, shock_with_brady
    Bridge to pacing (ACLS 2020 bradycardia algorithm)
    rxcui 3992
  • dopamine
    second line
    sympathomimetic
    5–20 mcg/kg/min • IV • continuous
    triggers: atropine_unresponsive_with_hypotension
    Chronotrope + inotrope (ACLS 2020 bradycardia algorithm)
    rxcui 3628

outpatient playbook — drug actions (2)

  1. 1. continue rate / rhythm regimen
    per chosen agent • PO • daily / BID
    trigger: Maintenance
    Symptom and recurrence control (ACC/AHA/HRS 2023 AF)
  2. 2. continue DOAC if AF burden
    apixaban / rivaroxaban / dabigatran / edoxaban • PO • daily / BID
    trigger: CHA2DS2-VASc indication
    Stroke prevention (ACC/AHA/HRS 2023 AF Class I)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Unexplained syncope or near-syncope (ACC/AHA/HRS 2018 Class I evaluation); Chronic fatigue / exercise intolerance (ACC/AHA/HRS 2018 SND symptom criteria); Palpitations alternating with brady episodes (ACC/AHA/HRS 2018 tachy-brady definition).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Brady-tachy syndrome / sick sinus syndrome** (cardio.brady_tachy_syndrome.v1).
Phenotype framing: SND vs AV block vs vagally mediated vs drug-induced vs ischemic vs infiltrative (ACC/AHA/HRS 2018 Section 4 differential)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute brady management before / pending pacemaker**.
1. atropine 0.5 mg IV q3–5 min, max 3 mg IV q3–5 min (antimuscarinic, first line) — ACLS 2020 bradycardia algorithm first-line; less effective in infranodal block (ACC/AHA/HRS 2018 Kusumoto)
2. isoproterenol 2–10 mcg/min IV continuous (beta_agonist, second line) — β1/β2 agonist increases SA rate; bridge to pacing (ACLS 2020; ACC/AHA/HRS 2018)
3. epinephrine 2–10 mcg/min IV continuous (sympathomimetic, second line) — Bridge to pacing (ACLS 2020 bradycardia algorithm)
4. dopamine 5–20 mcg/kg/min IV continuous (sympathomimetic, second line) — Chronotrope + inotrope (ACLS 2020 bradycardia algorithm)

Setting playbook (outpatient) — Long-term PPM management, AAD if needed, AC, lifestyle
5. continue rate / rhythm regimen per chosen agent PO daily / BID — Maintenance (Symptom and recurrence control (ACC/AHA/HRS 2023 AF))
6. continue DOAC if AF burden apixaban / rivaroxaban / dabigatran / edoxaban PO daily / BID — CHA2DS2-VASc indication (Stroke prevention (ACC/AHA/HRS 2023 AF Class I))

Non-pharmacologic actions:
- EP q3–6 mo (ACC/AHA/HRS 2018 Section 4.1)
- PPM check q3–12 mo (ESC 2021 pacing Section 7)
- OSA evaluation (ACC/AHA/HRS 2018 reversible-cause checklist)
- Vaccinations (AHA/ACC preventive care)

AVOID / contraindication checks:
- Atropine caution in AV block with wide escape
- Isoproterenol caution in CAD

Monitoring

Regimen monitoring:
- continuous ECG — ACLS 2020
- BP q5 min — ACLS 2020 bradycardia algorithm
- transcutaneous then transvenous pacing setup — ACC/AHA/HRS 2018 Class I

Setting (outpatient) monitoring:
- Remote PPM monitoring (ESC 2021 pacing Section 7)
- AF burden alerts (ACC/AHA/HRS 2023 AF; ASSERT Healey 2012)

Follow-up plan: EP q3–6 mo; PPM check; AC review; lifestyle — OSA management, exercise (ACC/AHA/HRS 2018; ESC 2021 pacing follow-up)
- Close-out criterion: Follow-up booked

Monitoring phase: Pacemaker interrogation; AF burden; symptom diary (ESC 2021 pacing Section 7 remote monitoring; ACC/AHA/HRS 2018)

Disposition

Current setting: outpatient — Long-term PPM management, AAD if needed, AC, lifestyle

Disposition criteria:
- Continue chronic management (ACC/AHA/HRS 2018; ESC 2021 pacing)

Escalation triggers (move to higher acuity):
- New syncope despite PPM → device interrogation (ACC/AHA/HRS 2018)
- High AF burden → AAD or ablation referral (ACC/AHA/HRS 2023 AF)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] SBP <90 with HR <50 and signs of shock
- [SEVERE] Syncope with documented sinus pause >3 s on monitor
- [SEVERE] Pause >3 s after spontaneous AF conversion

Citations

- 2018 ACC/AHA/HRS Bradycardia Guideline (Kusumoto) [PMID:30412709](https://pubmed.ncbi.nlm.nih.gov/30412709/)
- Cited evidence (PMID 12087119) [PMID:12087119](https://pubmed.ncbi.nlm.nih.gov/12087119/)
- Cited evidence (PMID 21870978) [PMID:21870978](https://pubmed.ncbi.nlm.nih.gov/21870978/)
- Cited evidence (PMID 12466506) [PMID:12466506](https://pubmed.ncbi.nlm.nih.gov/12466506/)

Last reconciled with current guidelines: 2026-04-27.
References