Overview of the 2025 bradycardia changes

Adult bradycardia management in 2025 continues to focus on identifying symptomatic bradycardia, supporting airway and breathing, and rapidly determining whether the slow heart rate is causing cardiopulmonary compromise. The updated materials reinforce that treatment is driven by symptoms and perfusion, not by heart rate alone, and they sharpen the decision points for pharmacologic therapy and pacing.

• Symptom‑driven treatment remains central: hypotension, altered mental status, signs of shock, ischemic chest discomfort, or acute heart failure continue to define unstable bradycardia.
• The algorithm retains the “identify and treat underlying cause” framework, but the cascade of boxes within the algorithm diagram more clearly separates observation from active intervention.
• Medication doses are confirmed and pacing/infusion options are grouped to simplify escalation when atropine fails or is unlikely to work.

Initial assessment and decision to treat

The 2025 Adult Bradycardia With a Pulse Algorithm continues to define clinically significant bradyarrhythmia as a heart rate typically less than 50 per minute in the presence of symptoms. The long‑description version of the algorithm uses numbered boxes to walk through assessment, decision about cardiopulmonary compromise, and subsequent actions.

• Bradycardia is again “heart rate typically < 50/min if bradyarrhythmia,” paired with assessment of blood pressure, mental status, signs of shock, chest pain, and heart failure.
• The early boxes emphasize airway, breathing, circulation support, oxygen as needed, cardiac monitoring, blood pressure monitoring, oximetry, IV access, and obtaining a 12‑lead ECG without delaying urgent therapy.
• If there is no evidence of cardiopulmonary compromise, the algorithm directs providers to identify and treat underlying causes and observe rather than immediately push drugs or initiate pacing.

Atropine and medication strategy

The 2025 algorithm confirms the higher atropine dose that replaced the older 0.5 mg recommendation in the prior cycle and keeps dopamine and epinephrine infusions as backup options. The dosing details are displayed directly under the algorithm to reduce ambiguity for providers.

• Atropine remains the first‑line drug for symptomatic bradycardia: 1 mg IV bolus, repeated every 3–5 minutes to a maximum total dose of 3 mg.
• Dopamine infusion dosing is reaffirmed as 5–20 mcg/kg per minute, titrated to patient response with slow taper when improving.
• Epinephrine infusion continues as an alternative chronotropic support option when atropine and/or pacing are ineffective or unavailable.
• The algorithm presentation reinforces that medications are indicated when the bradycardia is causing cardiopulmonary compromise and underlying causes cannot be rapidly corrected.

Pacing and escalation of care

In 2025, the role of pacing is more clearly framed as a rapid escalation step for unstable patients who do not respond promptly to atropine or for whom atropine is unlikely to be effective. The algorithm visually groups pacing and chronotropic infusions to help teams move quickly to more definitive support.

• Transcutaneous pacing is emphasized as a key therapy for persistent symptomatic bradycardia with cardiopulmonary compromise despite initial atropine.
• Dopamine and epinephrine infusions are listed alongside transcutaneous pacing as options for ongoing support when bradycardia persists.
• Expert consultation and transvenous pacing are highlighted as subsequent steps when initial measures fail or when high‑grade conduction disease is present.

Algorithm flow and structure

The 2025 bradycardia algorithm continues to use a cascading, numbered‑box format to present the sequence of assessment and treatment. This layout makes it easier to follow the stepwise progression from identification, through evaluation of compromise, to atropine, pacing, and infusions.

• Early boxes focus on assessment and determining whether the bradycardia is appropriate for the clinical condition or is causing compromise.
• Middle boxes outline atropine dosing and the decision to begin transcutaneous pacing and/or initiate dopamine or epinephrine infusions.
• Later boxes prompt teams to seek expert consultation, consider transvenous pacing, and continue to search for and treat reversible causes.

Return to Main 2015-2020 Guidelines Changes Page