Second 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] Mohammed Salih, M.D. Cafer Zorkun, M.D., Ph.D. [3] Syed Musadiq Ali M.B.B.S.[4]

Overview

Treatment for a Mobitz type I second-degree AV block (Wenckebach) is often not necessary. Occasionally Mobitz type 1 second degree AV blocks may result in bradycardia leading to hypotension and responds well to medications. If unresponsive to atropine or beta-adrenergic agonists, pacing (transcutaneous or transvenous) should be initiated for stabilization. If the patient is on any beta-blockers, calcium channel blockers or digoxin, the medications should be discontinued. All patients with Mobitz 1 block should be admitted and monitored. Treatment for a Mobitz type II involves initiating pacing as soon as this rhythm is identified. Mobitz type II second-degree AV blocks may imply structural damage to the AV conduction system. This rhythm often deteriorates into a complete heart block. These patients require transvenous pacing until a permanent pacemaker is placed. Unlike Mobitz type I second degree AV block (Wenckebach), Mobitz type II AV block often do not respond to atropine or beta-adrenergic agonists.

Medical Therapy

Recommendations for acute medical therapy for bradycardia associated atrioventricular block
Atropine (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

Beta adrenergic agonist (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

Aminophylline (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


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


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]


Mobitz I

Mobitz II

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. 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.
  3. 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.
  4. 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.
  5. 5.0 5.1 5.2 Mangi MA, Jones WM, Napier L. PMID 29493981. Missing or empty |title= (help)
  6. Hisamura M, Taguchi H, Hiraide A (January 2016). "Mobitz type 1 second-degree atrioventricular block by triazolam and brotizolam overdose". Acute Med Surg. 3 (1): 57–58. doi:10.1002/ams2.121. PMC 5667231. PMID 29123752.
  7. Kashou AH, Goyal A, Nguyen T, Chhabra L. PMID 29083636. Missing or empty |title= (help)
  8. Li X, Xue Y, Wu H (2018). "A Case of Atrioventricular Block Potentially Associated with Right Coronary Artery Lesion and Ticagrelor Therapy Mediated by the Increasing Adenosine Plasma Concentration". Case Rep Vasc Med. 2018: 9385017. doi:10.1155/2018/9385017. PMC 5933017. PMID 29850368.
  9. Barold SS, Herweg B (December 2012). "Second-degree atrioventricular block revisited". Herzschrittmacherther Elektrophysiol. 23 (4): 296–304. doi:10.1007/s00399-012-0240-8. PMID 23224264.
  10. Wogan JM, Lowenstein SR, Gordon GS (1993). "Second-degree atrioventricular block: Mobitz type II". J Emerg Med. 11 (1): 47–54. doi:10.1016/0736-4679(93)90009-v. PMID 8445186.


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