3 rd Degree AV block Jason Haag Heart Block 1 st Degree AV Block one-to-one relationship exists...
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![Page 1: 3 rd Degree AV block Jason Haag Heart Block 1 st Degree AV Block one-to-one relationship exists between P waves and QRS complexes, but the PR interval.](https://reader036.fdocuments.in/reader036/viewer/2022081506/5697c0301a28abf838cda7ab/html5/thumbnails/1.jpg)
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3rd Degree AV blockJason Haag
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Heart Block1st Degree AV Block
one-to-one relationship exists between P waves and QRS complexes, but the PR interval is longer than 200 ms
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Heart Block2nd Degree Mobitz Type I AV Block
(Wenckebach)PR interval is prolonging with each P wave to
the point when the P wave is no longer conducted
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Heart Block2nd Degree Mobitz Type II AV Block
PR interval is constant, but occasionally P waves are not followed by the QRS complexes
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Heart Block3rd Degree Heart Block
More P waves than the QRS complexes exist and no relationship exists between them
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3rd Degree Heart BlockBlock can be in AV node or infranodal
conduction systemAV node
2/3 escape rhythms have narrow QRS (junctional)Fascicular or bundle branches
Wide QRS (subjunctional)
Rate typically in low 40s
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FrequencyIn the US: 0.02%Internationally: 0.04%.
Age: Bimodal peak, at infancy given congenital complete AV block and at advance d age due to progressive fibrosis and ischemia
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HistorySyncope, near-syncope, and lightheadedness
Fatigue, dyspnea, and angina
Asymptomatic
Sudden cardiac death
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PhysicalVital Signs (stable vs. unstable, always check
HR manually)Signs of heart failure – JVD, a waves,
Pulmonary edemaNew murmurs or gallopsTarget lesions (Lyme)Splinter hemm, Osler nodes, etc
(endocarditis)Neuromuscular changes (mytonic/muscular
dystrophy)
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EtiologiesIdiopathic Progressive Cardiac Conduction Disease
½ of cases of AV blockLenegre’s disease
Progressive, fibrotic, sclerodegeneration of the conduction system
Younger individuals, may be hereditaryLev’s disease
Calcification extending from fibrous structures (aortic/mitral rings) into the conduction system
Older individuals, ? ESRDFibrosis NOS
Typically mitral and aortic rings Mitral narrow QRS Aortic wide QRS
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Etiologies (cont.)Ischemic heart disease
40% of casesEither from chronic ischemia or acute MI
Acute MI AV blocks (20% of patients) 1st degree (8%) 2nd degree (5%) 3rd degree (6%)
LBBB/RBBB (10-20%)AV nodal block (narrow QRS) associated with inferior
wall MIBundle blocks (wide QRS) associated with anterior
wall MIDrugs
Calcium channel blockers, beta blockers, digoxin, amiodarone, adenosine, quinidine, procainamide
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Etiologies (cont.)Infection
Lyme disease, endocarditis, Rheumatic fever, Chagas disease, myocarditis
Rheumatic diseaseAnkylosing spondylitis, Reiter syndrome,
relapsing polychondritis, rheumatoid arthritis, scleroderma
Infiltrative diseaseAmyloidosis, sarcoidosis, multiple myeloma,
hemachromatosis, Wilson’s disease
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EtiologiesHyperthyroidismMetabolic
Hypoxia, hyperkalemiaNeuromuscular disease
Muscular dystrophy, dermatomyositis
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TreatmentCorrect underlying problem – if you can
Correct K, stop AV blocking medications, etc.If unstable
Transcutaneous pacingIf stable
Plan for permanent pacemaker placement
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Permanent PacemakerClass I - Conditions for which evidence
and/or general agreement exists that a given procedure or treatment is beneficial, useful, and effectiveThird-degree AV block and advanced second-
degree AV block at any anatomic level associated with any one of the following conditions: Bradycardia with symptoms, heart failure,
arrhythmias, pauses greater than 3 seconds, escape rate < 40 bpm
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Permanent PacemakerClass IIa - Weight of evidence or opinion is in
favor of usefulness or efficacy Asymptomatic third-degree AV block at any
anatomic site with average awake ventricular rates of 40 bpm or faster, especially if cardiomegaly or left ventricular (LV) dysfunction is present
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References Gregoratos G, Abrams J, Epstein AE, et al: ACC/AHA/NASPE 2002
guideline update for implantation of cardiac pacemakers and antiarrhythmia devices: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2002 Oct 15; 106(16): 2145-61.
Kojic EM, Hardarson T, Sigfusson N, Sigvaldason H: The prevalence and prognosis of third-degree atrioventricular conduction block: the Reykjavik study. J Intern Med 1999 Jul; 246(1): 81-6.
McEnvoy GK, ed: AHFS Drug Information 2000. Bethesda, Md: American Society of Health-System Pharmacists; 2000: 1187-95.
Ostaner LD, Brandt RL, Kjelsberg MI, et al: Electrocardiographic findings among the adult population of a total natural community. 1965; 31: 888-98.
Rardon DA, Miles WM, Mitrani RD, et al: Electrocardiographic Recognition: Atrioventricular Block and Dissociation. In: Zipes DP, Jalife J, eds. Cardiac Electrophysiology From Cell to Bedside, 2nd ed. Philadelphia, Pa: WB Saunders; 1995.