Atrioventricular block

Atrioventricular block
ICD-10	I44.0-I44.3
ICD-9	426.0-426.1
MeSH	D006327

Atrioventricular block Microchapters
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Case #1
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: AV block

Diagnosis

History and Symptoms | Physical Examination | Laboratory Findings | Electrocardiogram | Chest X Ray | Echocardiography or Ultrasound | Other Imaging Findings | Other Diagnostic Studies

Treatment

Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

• Remove extrinsic causes
• Treat reversible intrinsic causes

Pharmacotherapy

Acute Pharmacotherapies

• Pharmacologic interventions (Atropine, Isoproterenol, Theophylline)

Surgery and Device Based Therapy

• Temporary Pacing
• Permant Pacing

Indications for Surgery and Device Based Therapy

Indications for Permanent Pacemaker in Acquired Atrioventricular Block in Adults (AHA, 1998)

• Class I

  • Third-degree AV block plus:

    • Symptoms related to bradycardia
    • Arrhythmia or other condition requiring nodal blockers
    • Asystole > 3 seconds (while awake), ventricular rate <40
    • Neuromeuscular disease

  • Second Degree AV block plus:

    • Symptomatic Bradycardia

• Class II

  • Asymptomatic Third-degree AV Block with HR >40
  • Asymptomatic Type II, second-degreee AV Block
  • Asymptomatic Type I, second-degree AV Block (with wide complex)

• Class III

  • Asymptomatic Type I, second-degree AV block (with narrow complex)

ACC / AHA Guidelines- Recommendations for Acquired Atrioventricular Block in Adults (DO NOT EDIT)

“

Class I 1. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level associated with bradycardia with symptoms (including heart failure) or ventricular arrhythmias presumed to be due to AV block. (Level of Evidence: C) 2. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level associated with arrhythmias and other medical conditions that require drug therapy that results in symptomatic bradycardia. (Level of Evidence: C) 3. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level in awake, symptom-free patients in sinus rhythm, with documented periods of asystole greater than or equal to 3.0 seconds86 or any escape rate less than 40 bpm, or with an escape rhythm that is below the AV node. (Level of Evidence: C) 4. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level in awake, symptom-free patients with AF and bradycardia with 1 or more pauses of at least 5 seconds or longer. (Level of Evidence: C) 5. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level after catheter ablation of the AV junction. (Level of Evidence: C) 6. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level associated with postoperative AV block that is not expected to resolve after cardiac surgery. (Level of Evidence: C) 7. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level associated with neuromuscular diseases with AV block, such as myotonic muscular dystrophy, Kearns-Sayre syndrome, Erb dystrophy (limb-girdle muscular dystrophy), and peroneal muscular atrophy, with or without symptoms. (Level of Evidence: B) 8. Permanent pacemaker implantation is indicated for second-degree AV block with associated symptomatic bradycardia regardless of type or site of block. (Level of Evidence: B) 9. Permanent pacemaker implantation is indicated for asymptomatic persistent third-degree AV block at any anatomic site with average awake ventricular rates of 40 bpm or faster if cardiomegaly or LV dysfunction is present or if the site of block is below the AV node. (Level of Evidence: B) 10. Permanent pacemaker implantation is indicated for second- or third-degree AV block during exercise in the absence of myocardial ischemia. (Level of Evidence: C) Class IIa 1. Permanent pacemaker implantation is reasonable for persistent third-degree AV block with an escape rate greater than 40 bpm in asymptomatic adult patients without cardiomegaly. (Level of Evidence: C) 2. Permanent pacemaker implantation is reasonable for asymptomatic second-degree AV block at intra- or infra-His levels found at electrophysiological study. (Level of Evidence: B) 3. Permanent pacemaker implantation is reasonable for first- or second-degree AV block with symptoms similar to those of pacemaker syndrome or hemodynamic compromise. (Level of Evidence: B) 4. Permanent pacemaker implantation is reasonable for asymptomatic type II second-degree AV block with a narrow QRS. When type II second-degree AV block occurs with a wide QRS, including isolated right bundle-branch block, pacing becomes a Class I recommendation. (See Section 2.1.3, “Chronic Bifascicular Block.”) (Level of Evidence: B) Class IIb 1. Permanent pacemaker implantation may be considered for neuromuscular diseases such as myotonic muscular dystrophy, Erb dystrophy (limb-girdle muscular dystrophy), and peroneal muscular atrophy with any degree of AV block (including first-degree AV block), with or without symptoms, because there may be unpredictable progression of AV conduction disease. (Level of Evidence: B) 2. Permanent pacemaker implantation may be considered for AV block in the setting of drug use and/or drug toxicity when the block is expected to recur even after the drug is withdrawn. (Level of Evidence: B) Class III 1. Permanent pacemaker implantation is not indicated for asymptomatic first-degree AV block. (Level of Evidence: B) (See Section 2.1.3, “Chronic Bifascicular Block.”) 2. Permanent pacemaker implantation is not indicated for asymptomatic type I second-degree AV block at the supra-His (AV node) level or that which is not known to be intra- or infra-Hisian. (Level of Evidence: C) 3. Permanent pacemaker implantation is not indicated for AV block that is expected to resolve and is unlikely to recur (e.g., drug toxicity, Lyme disease, or transient increases in vagal tone or during hypoxia in sleep apnea syndrome in the absence of symptoms). (Level of Evidence: B)

”

Case Studies

Case #1

Sources

• The ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities

References

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