Third degree AV block other diagnostic studies: Difference between revisions
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* In some cases, mobitz ttpe 1 [[atrioventricular block]] and [[narrow]] [[QRS]] complex contributes with infranodal [[atrioventricular block]]. | * In some cases, mobitz ttpe 1 [[atrioventricular block]] and [[narrow]] [[QRS]] complex contributes with infranodal [[atrioventricular block]]. | ||
* Event monitors, worn for 30 to 90 days, and [[ICDs]], which can be left in place for >2 years, tend to have greater diagnostic results than 24- to 48-hour ambulatory [[electrocardiographic monitoring]].<ref name="pmid12867227">{{cite journal |vauthors=Sivakumaran S, Krahn AD, Klein GJ, Finan J, Yee R, Renner S, Skanes AC |title=A prospective randomized comparison of loop recorders versus Holter monitors in patients with syncope or presyncope |journal=Am J Med |volume=115 |issue=1 |pages=1–5 |date=July 2003 |pmid=12867227 |doi=10.1016/s0002-9343(03)00233-x |url=}}</ref> | * Event monitors, worn for 30 to 90 days, and [[ICDs]], which can be left in place for >2 years, tend to have greater diagnostic results than 24- to 48-hour ambulatory [[electrocardiographic monitoring]].<ref name="pmid12867227">{{cite journal |vauthors=Sivakumaran S, Krahn AD, Klein GJ, Finan J, Yee R, Renner S, Skanes AC |title=A prospective randomized comparison of loop recorders versus Holter monitors in patients with syncope or presyncope |journal=Am J Med |volume=115 |issue=1 |pages=1–5 |date=July 2003 |pmid=12867227 |doi=10.1016/s0002-9343(03)00233-x |url=}}</ref> | ||
*[[Treadmill exercise stress testing]] can be used to identify the development of [[atrioventricular block]] and presence of [[ischemia]] as a precursor of [[atrioventricular block]].<ref name="pmid11703999">{{cite journal |vauthors=Barold SS |title=Lingering misconceptions about type I second-degree atrioventricular block |journal=Am J Cardiol |volume=88 |issue=9 |pages=1018–20 |date=November 2001 |pmid=11703999 |doi=10.1016/s0002-9149(01)01980-4 |url=}}</ref> | * [[Treadmill exercise stress testing]] can be used to identify the development of [[atrioventricular block]] and presence of [[ischemia]] as a precursor of [[atrioventricular block]].<ref name="pmid11703999">{{cite journal |vauthors=Barold SS |title=Lingering misconceptions about type I second-degree atrioventricular block |journal=Am J Cardiol |volume=88 |issue=9 |pages=1018–20 |date=November 2001 |pmid=11703999 |doi=10.1016/s0002-9149(01)01980-4 |url=}}</ref> | ||
* [[Treadmill exercise stress testing]] may be diagnostic to differentiate 2:1 atrioventricular block is Mobitz type I or II or identify the presence of [[infranodal]] disease.<ref name="pmid1191459">{{cite journal |vauthors=Bakst A, Goldberg B, Schamroth L |title=Significance of exercise-induced second degree atrioventricular block |journal=Br Heart J |volume=37 |issue=9 |pages=984–6 |date=September 1975 |pmid=1191459 |pmc=482908 |doi=10.1136/hrt.37.9.984 |url=}}</ref> | * [[Treadmill exercise stress testing]] may be diagnostic to differentiate 2:1 atrioventricular block is Mobitz type I or II or identify the presence of [[infranodal]] disease.<ref name="pmid1191459">{{cite journal |vauthors=Bakst A, Goldberg B, Schamroth L |title=Significance of exercise-induced second degree atrioventricular block |journal=Br Heart J |volume=37 |issue=9 |pages=984–6 |date=September 1975 |pmid=1191459 |pmc=482908 |doi=10.1136/hrt.37.9.984 |url=}}</ref> | ||
*[[Exercise]] causes [[vagal]] withdrawal and increased [[sympathetic]] tone leading to improved [[atrioventricular nodal conduction]]. | * [[Exercise]] causes [[vagal]] withdrawal and increased [[sympathetic]] tone leading to improved [[atrioventricular nodal conduction]]. | ||
* [[Exercise]] may worsen [[atrioventricular block]] by increased [[heart rate]] in the setting of [[infranodal]] [[atrioventricular block]].<ref name="pmid1191459">{{cite journal |vauthors=Bakst A, Goldberg B, Schamroth L |title=Significance of exercise-induced second degree atrioventricular block |journal=Br Heart J |volume=37 |issue=9 |pages=984–6 |date=September 1975 |pmid=1191459 |pmc=482908 |doi=10.1136/hrt.37.9.984 |url=}}</ref> | * [[Exercise]] may worsen [[atrioventricular block]] by increased [[heart rate]] in the setting of [[infranodal]] [[atrioventricular block]].<ref name="pmid1191459">{{cite journal |vauthors=Bakst A, Goldberg B, Schamroth L |title=Significance of exercise-induced second degree atrioventricular block |journal=Br Heart J |volume=37 |issue=9 |pages=984–6 |date=September 1975 |pmid=1191459 |pmc=482908 |doi=10.1136/hrt.37.9.984 |url=}}</ref> | ||
* In the presence of [[bundle branch block]] or [[hemiblock]] on resting [[ECG]], suspicion of episodic high-grade or complete [[atrioventricular block]] may raise. | * In the presence of [[bundle branch block]] or [[hemiblock]] on resting [[ECG]], suspicion of episodic high-grade or complete [[atrioventricular block]] may raise. | ||
* [[EPS]] may be helpful to determine the anatomic site of [[block]] in [[mobitz type 2]] [[atrioventricular block]] including [[atrioventricular node]], [[intra-His]], or [[infra-His]].<ref name="pmid7019962">{{cite journal |vauthors=Fisher JD |title=Role of electrophysiologic testing in the diagnosis and treatment of patients with known and suspected bradycardias and tachycardias |journal=Prog Cardiovasc Dis |volume=24 |issue=1 |pages=25–90 |date=1981 |pmid=7019962 |doi=10.1016/0033-0620(81)90026-8 |url=}}</ref> | * [[EPS]] may be helpful to determine the anatomic site of [[block]] in [[mobitz type 2]] [[atrioventricular block]] including [[atrioventricular node]], [[intra-His]], or [[infra-His]].<ref name="pmid7019962">{{cite journal |vauthors=Fisher JD |title=Role of electrophysiologic testing in the diagnosis and treatment of patients with known and suspected bradycardias and tachycardias |journal=Prog Cardiovasc Dis |volume=24 |issue=1 |pages=25–90 |date=1981 |pmid=7019962 |doi=10.1016/0033-0620(81)90026-8 |url=}}</ref> | ||
* The site of block In 70% of cases of 2:1 [[atrioventricular block]] with [[bundle branch block]] is infranodal block, however, 15% to 20% of these [[patients]] can have block in the [[atrioventricular node]]. | * The site of block In 70% of cases of 2:1 [[atrioventricular block]] with [[bundle branch block]] is infranodal block, however, 15% to 20% of these [[patients]] can have block in the [[atrioventricular node]].<ref name="pmid378457">{{cite journal |vauthors=Zipes DP |title=Second-degree atrioventricular block |journal=Circulation |volume=60 |issue=3 |pages=465–72 |date=September 1979 |pmid=378457 |doi=10.1161/01.cir.60.3.465 |url=}}</ref> | ||
* [[EPS]] can also determine the [[bradycardia]] due to [[extrasystole]] which is similar to [[atrioventricular block]] on resting [[ECG]]. | * [[EPS]] can also determine the [[bradycardia]] due to [[extrasystole]] which is similar to [[atrioventricular block]] on resting [[ECG]]. | ||
* [[Carotid sinus massage]] is useful to determine the type of [[atrioventricular block]] When 2:1 [[atrioventricular block]] or Mobitz type I [[atrioventricular]] block in the setting of a [[wide QRS complex]] can not be differentiated on resting [[ECG]]. | * [[Carotid sinus massage]] is useful to determine the type of [[atrioventricular block]] When 2:1 [[atrioventricular block]] or Mobitz type I [[atrioventricular]] block in the setting of a [[wide QRS complex]] can not be differentiated on resting [[ECG]]. | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Soroush Seifirad, M.D.[2]
Overview
Other diagnostic studies for third-degree AV block include diagnostic electrophysiologic studies, which may demonstrate atrioventricular (AV) conduction abnormalities and help to determine the level of the block.Ambulatory monitoring is warranted in cases of possible transient heart block, or some other bradyarrhythmias that might be mistaken with third-degree AV block. Cardiac catheterization or stress testing is warranted if ischemic heart disease is suspected.
Other Diagnostic Studies
| Other diagnostic testing for bradycardia associated atrioventricular block |
| (Class IIa, Level of Evidence B): |
|
❑ambulatory electrocardiographic monitoring is recommended in the presence of first degree atrioventricular block or second degree atrioventricular block mobitz type 1 on ECG with symptoms of bradycardia (dizziness, faint) and unclear etiology, to establish correlation between symptoms and rhythm abnormalities. |
| (Class IIa, Level of Evidence C): |
|
❑Exercise treadmill test is recommended in the presence of chest pain or shortness of breath during exercise and first degree or second degree atrioventricular block during rest ECG |
| (Class IIb, Level of Evidence B): |
|
❑EPS is reasonable in second degree atrioventricular block for determining the level of block and benefit of PPM |
| (Class IIb, Level of Evidence C): |
|
❑ Carotid sinus massage or pharmacological challenge with atropine or isoproterenol, procainamide can be used in patients with second degree atrioventricular block to determine the level of block and the need for PPM insertion |
- Electrocardiographic monitoring can be used to identify the changes in QRS morphology such as alternating bundle branch block.
- Mobitz type1 atrioventricular block is much more associated with narrow QRS morphology and mobitz type 2 atrioventricular block usually has wide QRS morphology'
- In some cases, mobitz ttpe 1 atrioventricular block and narrow QRS complex contributes with infranodal atrioventricular block.
- Event monitors, worn for 30 to 90 days, and ICDs, which can be left in place for >2 years, tend to have greater diagnostic results than 24- to 48-hour ambulatory electrocardiographic monitoring.[1]
- Treadmill exercise stress testing can be used to identify the development of atrioventricular block and presence of ischemia as a precursor of atrioventricular block.[2]
- Treadmill exercise stress testing may be diagnostic to differentiate 2:1 atrioventricular block is Mobitz type I or II or identify the presence of infranodal disease.[3]
- Exercise causes vagal withdrawal and increased sympathetic tone leading to improved atrioventricular nodal conduction.
- Exercise may worsen atrioventricular block by increased heart rate in the setting of infranodal atrioventricular block.[3]
- In the presence of bundle branch block or hemiblock on resting ECG, suspicion of episodic high-grade or complete atrioventricular block may raise.
- EPS may be helpful to determine the anatomic site of block in mobitz type 2 atrioventricular block including atrioventricular node, intra-His, or infra-His.[4]
- The site of block In 70% of cases of 2:1 atrioventricular block with bundle branch block is infranodal block, however, 15% to 20% of these patients can have block in the atrioventricular node.[5]
- EPS can also determine the bradycardia due to extrasystole which is similar to atrioventricular block on resting ECG.
- Carotid sinus massage is useful to determine the type of atrioventricular block When 2:1 atrioventricular block or Mobitz type I atrioventricular block in the setting of a wide QRS complex can not be differentiated on resting ECG.
- Use of procainamide in patients with bifascicular block was associated with prolonged H-V interval indicating infranodal atrioventricular block. [6]
- Atropine may improve or have no change in atrioventricular conduction block if the block is at the level of the atrioventricular node but may worsen atrioventricular conduction block in the presence of intra-His or distal conduction disease.
- Isoproterenol is useful to determine the underlying pathologic His-Purkinje disease by enhancing atrioventricular nodal and sinus conduction and precipitating heart block with faster heart rates.
- Worsening atrioventricular block with isoproterenol and atropine may be suggestive of infranodal block.
- Improvement of atrioventricular conduction with carotid sinus massage may be observed in patients with infranodal atrioventric-ular block.[7]
References
- ↑ Sivakumaran S, Krahn AD, Klein GJ, Finan J, Yee R, Renner S, Skanes AC (July 2003). "A prospective randomized comparison of loop recorders versus Holter monitors in patients with syncope or presyncope". Am J Med. 115 (1): 1–5. doi:10.1016/s0002-9343(03)00233-x. PMID 12867227.
- ↑ Barold SS (November 2001). "Lingering misconceptions about type I second-degree atrioventricular block". Am J Cardiol. 88 (9): 1018–20. doi:10.1016/s0002-9149(01)01980-4. PMID 11703999.
- ↑ 3.0 3.1 Bakst A, Goldberg B, Schamroth L (September 1975). "Significance of exercise-induced second degree atrioventricular block". Br Heart J. 37 (9): 984–6. doi:10.1136/hrt.37.9.984. PMC 482908. PMID 1191459.
- ↑ Fisher JD (1981). "Role of electrophysiologic testing in the diagnosis and treatment of patients with known and suspected bradycardias and tachycardias". Prog Cardiovasc Dis. 24 (1): 25–90. doi:10.1016/0033-0620(81)90026-8. PMID 7019962.
- ↑ Zipes DP (September 1979). "Second-degree atrioventricular block". Circulation. 60 (3): 465–72. doi:10.1161/01.cir.60.3.465. PMID 378457.
- ↑ Twidale N, Heddle WF, Tonkin AM (October 1988). "Procainamide administration during electrophysiology study--utility as a provocative test for intermittent atrioventricular block". Pacing Clin Electrophysiol. 11 (10): 1388–97. PMID 2462213.
- ↑ Mangiardi LM, Bonamini R, Conte M, Gaita F, Orzan F, Presbitero P, Brusca A (April 1982). "Bedside evaluation of atrioventricular block with narrow QRS complexes: usefulness of carotid sinus massage and atropine administration". Am J Cardiol. 49 (5): 1136–45. doi:10.1016/0002-9149(82)90037-6. PMID 7064840.