Bradycardia in the emergency department: quality gaps and opportunities for improvement

Introduction Bradycardia in the emergency department (ED) ranges from physiologic to life-threatening. We sought to compare quality measures, and opportunities for improvement. Methods This retrospective chart review evaluated patients admitted through two academic EDs from July 2024 to June 2025 with triage heart rate < 50. Hospital course was reviewed to stratify bradycardia as primary (required a permanent pacemaker), secondary (required treatment of a secondary cause), or none. ED chart review compared physician ECG interpretation with blinded interpretation, and evaluated ED treatments. Results There were 198 patients: 62 primary, 68 secondary, and 68 neither. Secondary bradycardias were more likely to have BP < 90 mmHg (19.1 vs 6.5%, p < 0.05) and higher mortality (25.0 vs 4.8%, p < 0.05) than primary bradycardias. Primary bradycardias had delayed recognition of subtle AV block including atrial fibrillation/flutter with 3rd degree AV block, and attempted cardioversion for atrial fibrillation with slow ventricular response. ECG-to-intervention time was rapid for bradycardia secondary to opioid overdose (1 min to naloxone) and intracranial emergencies (62 min to CT) despite the lack of ECG changes, but longer for myocardial infarction (76 min to aspirin) and hyperkalemia (111 min to calcium) despite ECG changes. ECG-to-warming was 26 min for environmental hypothermia but 112 min for hypothermic sepsis. Conclusion Secondary bradycardias were more hypotensive and had higher mortality. In our centre, primary bradycardia can be improved for subtle AV blocks and atrial fibrillation with complete AV block, and secondary bradycardias can be improved for hyperkalemia, hypothermic sepsis, and cardiac ischemia. This quality improvement framework could be replicated.