Paroxysmal AV Block other diagnostic studies

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

Overview

An Implantable Cardiac Monitor is almost exclusively used in the diagnosis of bradycardia related disorders such as high-grade atrioventricular block, sinus node dysfunction and neurocardiogenic syncope (with predominant cardio-inhibitory component). This prolonged monitoring (up to 3 years) can help correlate bradycardia conduction disorders with symptoms. An EPS is an invasive catheter based procedure that is employed to detect and anatomically locate conduction disorders. An increased HH interval is seen in intrinsic paroxysmal AV Block. Certain maneuvers cause an increase in vagal surge and may precipitate symptoms in extrinsic vagal paroxysmal AV block. These include carotid sinus massage and tilt table testing.

Implantable Loop Recorder

  • Implantable loop recorders are useful tools as they help correlate electrical tracings with the patients symptoms during an acute event.
  • According to the European Society of Cardiology, the indication for implantable loop recorders are as follows :
    1. In the early phase of evaluation in patients with recurrent syncope of uncertain origin, absence of high risk criteria and a high likelihood of recurrence within the battery life of the device
    2. In patients with suspected or certain reflex syncope presenting with frequent or severe syncopal episodes
    3. In patients whom epilepsy was suspected but the treatment has proven ineffective.
    4. In patients with unexplained falls. "ESC Guidelines on Syncope (Diagnosis and Management of)".
ISSUE ECG Classification-"ESC Guidelines on Syncope (Diagnosis and Management of)".
  • The ISSUE 2 study (characterized by a frequently injured elderly population with a history of recurrent syncope) demonstrated the importance of implantable loop recorders (ILR) as a diagnostic modality by showing that the recurrence rate in syncope patients treated with ILR based therapy was much lower than those treated with no-specific therapy.
    • In addition, a recurrence rate of 5% was noted in those treated with cardiac pacing.[3]

2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay:Recommendation for Implantable Cardiac Monitor

Recommendation for Implantable Cardiac Monitor
"1. In patients with infrequent symptoms (>30 days between symptoms) suspected to be caused by bradycardia, longterm ambulatory monitoring with an implantable cardiac monitor (ICM) is reasonable if initial noninvasive evaluation is nondiagnostic.(Level of Evidence: C-LD) "

Electrophysiologic studies (EPS)

  • The decision to perform an EPS requires a global risk assessment.
    • The application of this study is most important in diagnosing I-AVB.
  • According to the European Society of Cardiology, indications for EPS are as follows :
    1. In patients with syncope and previous myocardial infarction or other scar related conditions, EPS is indicated when syncope remains unexplained after non- invasive evaluation.
    2. In patients with syncope and asymptomatic sinus bradycardia, EPS may be considered in a few instances where no invasive tests (eg. ECG monitoring) have failed to show a correlation between syncope and bradycardia.
    3. In patients with syncope preceded by sudden and brief palpitations, EPS may be considered when syncope remains unexplained after non invasive evaluation. "ESC Guidelines on Syncope (Diagnosis and Management of)".

EPS guided therapy

  • A 42 month follow up was performed by Gronda et al in 155 patients, majority of whom had a history of previous syncope.
EPS significance-"Syncope and paroxysmal atrioventricular block - Aste - 2017 - Journal of Arrhythmia - Wiley Online Library".

2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay

Recommendation for Electrophysiology Testing
"1. In patients with symptoms suspected to be attributable to bradycardia, an electrophysiology study (EPS) may be considered in selected patients for diagnosis of, and elucidation of bradycardia mechanism, if initial noninvasive evaluation is nondiagnostic(Level of Evidence: C-LD)[4]"

Vagal Maneuvers : Carotid Sinus massage and Tilt Table testing

Carotid Sinus Massage- "ESC Guidelines on Syncope (Diagnosis and Management of)".

References

  1. Guerrero-Márquez FJ, Arana-Rueda E, Pedrote A (2016). "Idiopathic Paroxysmal Atrio-Ventricular Block. What is The Mechanism?". J Atr Fibrillation. 9 (3): 1449. doi:10.4022/jafib.1449. PMC 5368548. PMID 28496928.
  2. Brignole M, Moya A, Menozzi C, Garcia-Civera R, Sutton R (2005). "Proposed electrocardiographic classification of spontaneous syncope documented by an implantable loop recorder". Europace. 7 (1): 14–8. doi:10.1016/j.eupc.2004.11.001. PMID 15670961.
  3. Brignole M, Sutton R, Menozzi C, Garcia-Civera R, Moya A, Wieling W; et al. (2006). "Early application of an implantable loop recorder allows effective specific therapy in patients with recurrent suspected neurally mediated syncope". Eur Heart J. 27 (9): 1085–92. doi:10.1093/eurheartj/ehi842. PMID 16569653.
  4. 4.0 4.1 4.2 Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR; et al. (2019). "2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society". J Am Coll Cardiol. 74 (7): 932–987. doi:10.1016/j.jacc.2018.10.043. PMID 30412710.
  5. Gronda M, Magnani A, Occhetta E, Sauro G, D'Aulerio M, Carfora A; et al. (1984). "Electrophysiological study of atrio-ventricular block and ventricular conduction defects. Prognostic and therapeutical implications". G Ital Cardiol. 14 (10): 768–73. PMID 6519386.
  6. Brignole M, Arabia F, Ammirati F, Tomaino M, Quartieri F, Rafanelli M; et al. (2016). "Standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncope: 3-year insights from the Syncope Unit Project 2 (SUP 2) study". Europace. 18 (9): 1427–33. doi:10.1093/europace/euv343. PMID 26612880.


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