Third degree AV block medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3] Raviteja Guddeti, M.B.B.S. [4] Soroush Seifirad, M.D.[5] Qasim Khurshid, M.B.B.S. [5]

Overview

The management of third-degree AV block depends on the severity of signs, symptoms, and the underlying cause. In symptomatic patients and with hemodynamic distress, pharmacological therapy should be initiated immediately to increase heart rate and cardiac output. Most of the patients who do not respond to pharmacologic therapy require a temporary pacemaker. After stabilizing the patients, assessment and treatment of potentially reversible causes should be done. Some patients without reversible cause or unidentified etiology require a permanent pacemaker.

Medical Therapy

Recommendations for Acute Management of Bradycardia Attributable to Atrioventricular Block
Symptomatic sinus bradycardia or atrioventricular block

Atropine 0.5-1 mg IV (may be repeated every 3-5 min to a maximum dose of 3 mg)
Dopamine 5 to 20 mcg/kg/min IV, starting at 5 mcg/kg/min and increasing by 5 mcg/kg/min every 2 min
Dosages of >20 mcg/kg/min may lead to vasoconstriction or arrhythmias

Isoproterenol 20-60 mcg IV bolus followed doses of 10-20 mcg, or infusion of 1-20 mcg/min based on heart rate response
Monitoring of ischemic chest pain

Epinephrine 2-10 mcg/min IV or 0.1-0.5 mcg/kg/min IV titrated to desired effect

Second or third degree atrioventricular block associated acute inferior MI :

Aminophylline 250-mg IV bolus

Calcium channel blocker overdose

❑ 10% calcium chloride 1-2 g IV every 10-20 min or an infusion of 0.2-0.4 mL/kg/h
❑ 10% calcium gluconate 3-6 g IV every 10-20 min or an infusion at 0.6-1.2 mL/kg/h

Betablocker or Calcium channel blocker overdose

Glucagon 3-10 mg IV with infusion of 3-5 mg/h
❑ High dose insulin therapy IV bolus of 1 unit/kg followed by an infusion of 0.5 units/kg/h
Checking potassium and glocagon level

Digoxin overdose

Digoxin antibody fragment
Every vial for 0.5 mg of digoxin, over 30 min, maybe repeated

❑ Dosage is dependent on the amount ingested or known digoxin concentration

Post heart transplant

Aminophylline 6 mg/kg in 100-200 mL of IV fluid over 20-30 min
Theophylline 300 mg IV, followed by oral dose of 5-10 mg/kg/d
Therapeutic serum level 10-20 mcg/mL, posttransplant dosages average 450 mg±100 mg/d

Spinal cord injury

Aminophylline 6 mg/kg in 100-200 mL of IVfluid over 20-30 min
Theophylline Oral dose of 5-10 mg/kg/d titrated to effect
Effective serum level 10-20 mcg/mL


The above table adopted from 2018 AHA/ACC/HRS Guideline[1]



Class IIa
"1 Digoxin Fab antibody fragment is recommended in patients presented with digoxin toxicity resulting in symptomatic bradycardia or hemodynamic compromised. (Level of Evidence C)"
Class III
"2 Dialysis is not benefit in patients presented with bradycardia associated digoxin toxicity (Level of Evidence C)"











Recommendations for Acute Management of Reversible Causes of Bradycardia Attributable to Atrioventricular Block
Medical therapy (Class I, Level of Evidence B):

❑ In patients with transient or reversible causes of atrioventricular block including Lyme carditis or drug toxicity, medical therapy and transient pace maker insertion is recommended before making decision for implantation of PPM

PPM implantation ( Class IIa, Level of Evidence B) :

❑ In patients with symptomatic second-degree or third-degree atrioventricular block who are on chronic stable doses of medically necessary antiarrhythmic or beta-blocker therapy, PPM is recommended without further evaluation about drug washout or reversibility
❑ In patients with second-degree or third-degree atrioventricular block associated with cardiac sarcoidosis, PPM with defibrillation is recommended if life expectancy > 1 year, without further evaluation about reversibility

PPM implantation : (Class IIb, Level of Evidence C)

❑ In patients with symptomatic second-degree or third-degree atrioventricular block associated with thyroid function abnormalities but without clinical myxedema, PPM is recommended without further evaluation about reversibility

Abbreviations: PPM: Permanent pacemaker;

The above table adopted from 2018 AHA/ACC/HRS Guideline[1]

Notes


Recommendations for acute medical therapy for bradycardia associated atrioventricular block
Medical therapy (Class IIa, Level of Evidence C):

Atropine is reasonable for patients with symptomatic bradycardia associated second-degree or third degree atrioventricular block at the atrioventricular nodal level

Medical therapy (Class IIb, Level of Evidence B):

Beta adrenergic agonist such as isoproterenol, dopamine, dobutamine is recommended for symptomatic bradycardia associated second degree or third degree atrioventricular block with low likehood of ischemia

Medical therapy (Class IIb, Level of Evidence C):

Aminophylline is recommended for symptomatic bradycardia associated second or third degree atrioventricular block in the setting of acute inferior MI

Comment

References

  1. 1.0 1.1 Kusumoto, Fred M.; Schoenfeld, Mark H.; Barrett, Coletta; Edgerton, James R.; Ellenbogen, Kenneth A.; Gold, Michael R.; Goldschlager, Nora F.; Hamilton, Robert M.; Joglar, José A.; Kim, Robert J.; Lee, Richard; Marine, Joseph E.; McLeod, Christopher J.; Oken, Keith R.; Patton, Kristen K.; Pellegrini, Cara N.; Selzman, Kimberly A.; Thompson, Annemarie; Varosy, Paul D. (2019). "2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society". Circulation. 140 (8). doi:10.1161/CIR.0000000000000628. ISSN 0009-7322.
  2. 2.0 2.1 Chan BS, Buckley NA (2014). "Digoxin-specific antibody fragments in the treatment of digoxin toxicity". Clin Toxicol (Phila). 52 (8): 824–36. doi:10.3109/15563650.2014.943907. PMID 25089630.
  3. Forrester, J. D.; Mead, P. (2014). "Third-Degree Heart Block Associated With Lyme Carditis: Review of Published Cases". Clinical Infectious Diseases. 59 (7): 996–1000. doi:10.1093/cid/ciu411. ISSN 1058-4838.
  4. Antman, E M; Wenger, T L; Butler, V P; Haber, E; Smith, T W (1990). "Treatment of 150 cases of life-threatening digitalis intoxication with digoxin-specific Fab antibody fragments. Final report of a multicenter study". Circulation. 81 (6): 1744–1752. doi:10.1161/01.CIR.81.6.1744. ISSN 0009-7322.
  5. Kennebäck, Göran; Tabrizi, Fariborz; Lindell, Peter; Nordlander, Rolf (2007). "High-degree atrioventricular block during anti-arrhythmic drug treatment: use of a pacemaker with a bradycardia-detection algorithm to study the time course after drug withdrawal". EP Europace. 9 (3): 186–191. doi:10.1093/europace/eul185. ISSN 1532-2092.
  6. Osmonov, Damirbek; Erdinler, Izzet; Ozcan, Kazim Serhan; Altay, Servet; Turkkan, Ceyhan; Yildirim, Ersin; Hasdemir, Hakan; Alper, Ahmet Taha; Cakmak, Nazmiye; Satilmis, Seckin; Gurkan, Kadir (2012). "Management of Patients with Drug-Induced Atrioventricular Block". Pacing and Clinical Electrophysiology. 35 (7): 804–810. doi:10.1111/j.1540-8159.2012.03410.x. ISSN 0147-8389.
  7. Kandolin R, Lehtonen J, Kupari M (June 2011). "Cardiac sarcoidosis and giant cell myocarditis as causes of atrioventricular block in young and middle-aged adults". Circ Arrhythm Electrophysiol. 4 (3): 303–9. doi:10.1161/CIRCEP.110.959254. PMID 21427276.
  8. Ozcan, Kazim Serhan; Osmonov, Damirbek; Erdinler, Izzet; Altay, Servet; Yildirim, Ersin; Turkkan, Ceyhan; Hasdemir, Hakan; Cakmak, Nazmiye; Alper, Ahmet Taha; Satilmis, Seckin; Gurkan, Kadir (2012). "Atrioventricular block in patients with thyroid dysfunction: Prognosis after treatment with hormone supplementation or antithyroid medication". Journal of Cardiology. 60 (4): 327–332. doi:10.1016/j.jjcc.2012.05.012. ISSN 0914-5087.
  9. Hatle L, Rokseth R (July 1971). "Conservative treatment of AV block in acute myocardial infarction. Results in 105 consecutive patients". Br Heart J. 33 (4): 595–600. doi:10.1136/hrt.33.4.595. PMC 487219. PMID 5557475.
  10. Morrison LJ, Long J, Vermeulen M, Schwartz B, Sawadsky B, Frank J, Cameron B, Burgess R, Shield J, Bagley P, Mausz V, Brewer JE, Dorian P (March 2008). "A randomized controlled feasibility trial comparing safety and effectiveness of prehospital pacing versus conventional treatment: 'PrePACE'". Resuscitation. 76 (3): 341–9. doi:10.1016/j.resuscitation.2007.08.008. PMC 7126680 Check |pmc= value (help). PMID 17933452.
  11. Hurley KF, Magee K, Green R (November 2015). "Aminophylline for bradyasystolic cardiac arrest in adults". Cochrane Database Syst Rev (11): CD006781. doi:10.1002/14651858.CD006781.pub3. PMID 26593309.

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