Introduction

Bradycardia is a prevalent arrhythmia cardiac event in many populations. This is manifested as a heart rate of less than 50-60 beats per minute. It is quite common among young athletes and in the ageing population. Treatment is usually recommended where the heart rate is lower than an arbitrary cutoff or where a pause is above a recommended duration. Some symptoms of bradycardia include presyncope, syncope, lightheadedness, extreme tiredness, confusion, hypoperfusion, and sometimes symptoms of heart failure. A comprehensive patient history, physical health evaluation, as well as and ambulatory Electrocardiography (ECG) monitoring, are usually used as the diagnostic tool of choice or to assess the correlation between symptoms and rhythm to support diagnosis and to facilitate good clinical decision-making. There is a recommendation by the 2018 Bradycardia Guideline on a focus on disease-based management and symptomatic assessment.¹

Bradycardia is commonly observed in geriatric patients. The cause usually varies; however, cardiac pacing is an effective management of the disease condition. Pharmacologic therapeutic methods such as intravenous isoproterenol, atropine, and oral anticholinergics, including prazosin, hydralazine, and theophylline are available options for the management of the condition.^1,2

Understanding Bradycardia

Bradycardia is regarded as a heart rate lower than the normal range value concerning the age of the individual. In the assessment of individual heart rates, it is essential to properly identify the rhythm as well as the aetiology. This is because a healthy heart of an athlete may seem like it manifests bradycardia symptoms and just as well, these manifestations, if further examined, may be an indication of a conductive tissue disease.

Bradycardia usually shows as junctional bradycardia, atrioventricular block, or sinus bradycardia.³

Bradycardia in the elderly

When bradycardia occurs, it is often accompanied by a reduction in cardiac outputs, hypoperfusion, and hypotension. The causes of bradycardia are mainly subdivided into two broad categories, first, it could be due to the abnormal conduction of the heart’s electrical signal as seen in the atrioventricular node and abnormal sinus node. Secondly, determinants such as pulmonary embolism, abnormal metabolism, myocardial infarction, some infections, and certain medications such as beta-adrenergic -blockers, calcium channel blockers, digoxin, and cholinergic agents. This is prevalent among elderly individuals. A study in an Emergency department in Singapore found that chest pain due to bradycardia accounted for up to 29.6 % of all cardiac events.⁴

There is limited data on how prevalent bradycardia is among the older population and the health outcomes afterwards. Bradycardia results from a conduction block which fails the propagation of impulses. Underlying conditions such as hyperkalaemia, toxicity of the calcium channels, and toxicity of the beta-adrenergic receptor blockers have been known to cause bradycardia. There is also asymptomatic bradycardia which may be considered a normal cardiac rhythm. Treatment of symptomatic conduction blocks is usually by using pacemakers, vagal inhibitors, and sympathomimetic agents.

The choice of treatment options usually depends on the symptom, its duration, its severity, as well as the possibility of reversing the symptom by modifying the factors causing the condition. Furthermore, management strategies are usually influenced by findings from vital signs, systemic consequences of bradycardia, including kidney function among others, type of bradycardia, and the effect of pharmacological options available. However, even suspected bradycardia usually requires close attention to avoid asystole and protect against tachycardia while improving haemodynamic status.^5,6

It is worthy of note that bradycardia is not a disease in itself, it can occur among very athletic individuals as well as in the course of sleep. However, it is quite common among the elderly. This is attributed to the ageing process as well as associated consequences of the worsening of some disease conditions. It is necessary to appropriately identify bradycardia because symptomatic bradycardia can result in deadly complications if poorly managed or dismissed as a non-threatening condition. Therefore, a detailed medical history is essential. It is important to obtain information on medications taken and identify comorbidities and the aetiology of the patient.

The healthcare provider must obtain comprehensive information on family history, comorbidities, presence of mixed pathologies, and overall cardiovascular health- the patient’s blood pressure and ECG must be closely monitored. It is also important to treat underlying conditions where present because it is associated with different pathological and physiological conditions which can be life-threatening if left unattended. In essence, management is dependent on if the condition is deadly in the acute attack or could pose danger in the future. Where the patient suffers from irreversible bradycardia, permanent pacing is the choicest therapeutic option.⁷

Many studies have shown that there is a cumulative improvement in the survival rates (up to 5 years) in about 50 % of octogenarians and nonagenarians. However, it also comes with its risk, especially in association with some comorbidities such as heart failure, diabetes, and coronary heart diseases at the time of pacemaker implantation. Age and gender have also been found to be determining factors of mortality rates. Advanced age and the male gender are more at risk and tend to show worse survival rates.

Summary

Bradycardia is characterized by a heart rate of less than 50 to 60 beats per minute. It is a common arrhythmia observed in various populations, especially among the elderly. Symptoms may include presyncope, syncope, lightheadedness, confusion, and hypoperfusion. Diagnostic evaluation typically involves a comprehensive patient history, physical examination, and ambulatory ECG monitoring. Treatment options may vary depending on the underlying cause and may include pharmacologic therapy or cardiac pacing.

In the elderly, bradycardia often results from abnormalities in the heart’s electrical conduction system or some underlying medical conditions such as myocardial infarction or even as a side effect of a medication. The management strategies aim to eliminate the manifesting symptoms as well as to ensure there are limited or no complications. The therapeutic options are influenced by the severity, duration, and reversibility of the condition. The vital signs must be closely monitored to avoid adverse outcomes.

Bradycardia can occur in healthy individuals. However, the prevalence of the condition is elevated with advancement in age and the worsening of co-existing medical conditions. It is essential to accurately identify bradycardia to ensure there are no complications which may end up being life-threatening to the patient. Detailed medical history and family history, ECG and vital signs monitoring, and addressing underlying medical conditions. Permanent pacing may be used where the bradycardia is reversible.

In brevity, it is important to recognize the significance of bradycardia particularly in the elderly, appropriate diagnostic and therapeutic interventions must be adopted to ensure optimal outcomes and quality of life. Scientific findings have shown that the age and gender of each individual are determining factors in the survival rates after cardiac pacing treatments. Advancement in age and the male gender seems to be more at risk of lower survival rates after treatments.