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| Image = First Degree AV Block.jpg | | | Image = First Degree AV Block.jpg | |
| Caption = | | | Caption = | |
| DiseasesDB = |
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| ICD10 = {{ICD10|I|44|0|i|30}}-{{ICD10|I|44|3|i|30}} |
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| ICD9 = {{ICD9|426.0}}-{{ICD9|426.1}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = |
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| eMedicineSubj = |
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| eMedicineTopic = |
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| MeshID = D006327 |
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| }} | | }} |
| {{Atrioventricular block}} | | {{Atrioventricular block}} |
| {{CMG}}
| | '''For patient information, click [[Heart block (patient information)|here]]''' |
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| {{SK}} AV block | | {{CMG}}; {{AE}} {{EdzelCo}} |
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| | {{SK}} AV block; AV nodal block |
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| == [[Atrioventricular block overview|Overview]] == | | == [[Atrioventricular block overview|Overview]] == |
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| == [[Atrioventricular block risk factors|Risk Factors]] == | | == [[Atrioventricular block risk factors|Risk Factors]] == |
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| == [[Atrioventricular block screening|Screening]] == | | == [[Atrioventricular block natural history, complications and prognosis|Natural History, Complications and Prognosis]] == |
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| == [[Atrioventricular block natural history, complications and prognosis|Natural History, Complications and Prognosis]] == | | == Diagnosis == |
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| | [[Atrioventricular block history and symptoms|History and Symptoms]] | [[Atrioventricular block physical examination|Physical Examination]] | [[Atrioventricular block laboratory findings|Laboratory Findings]] | [[Atrioventricular block electrocardiogram|Electrocardiogram]] | [[Atrioventricular block EKG examples|EKG Examples]] | [[Atrioventricular block chest x ray|Chest X Ray]] | [[Atrioventricular block echocardiography|Echocardiography]] | [[Atrioventricular block other diagnostic studies|Other Diagnostic Studies]] |
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| == Treatment == | | == Treatment == |
| * Remove extrinsic causes
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| * Treat reversible intrinsic causes
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| == Pharmacotherapy ==
| | [[Atrioventricular block medical therapy|Medical Therapy]] | [[Atrioventricular block surgery|Surgery]] | [[Atrioventricular block primary prevention|Primary Prevention]] | [[Atrioventricular block secondary prevention|Secondary Prevention]] | [[Atrioventricular block cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Atrioventricular block future or investigational therapies|Future or Investigational Therapies]] |
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| === Acute Pharmacotherapies === | | ==Case Studies== |
| * Pharmacologic interventions (Atropine, Isoproterenol, Theophylline)
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| == Surgery and Device Based Therapy ==
| | [[Atrioventricular block case study one|Case #1]] |
| * Temporary Pacing
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| * Permant Pacing
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| === Indications for Surgery and Device Based Therapy ===
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| '''Indications for Permanent Pacemaker in Acquired Atrioventricular Block in Adults (AHA, 1998)'''
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| | [[CME Category::Cardiology]] |
| * ''Class I''
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| *:* Third-degree AV block plus:
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| *:*:* Symptoms related to bradycardia
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| *:*:* Arrhythmia or other condition requiring nodal blockers
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| *:*:* Asystole > 3 seconds (while awake), ventricular rate <40
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| *:*:* Neuromeuscular disease
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| *:* Second Degree AV block plus:
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| *:*:* Symptomatic Bradycardia
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| * ''Class II''
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| *:* Asymptomatic Third-degree AV Block with HR >40
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| *:* Asymptomatic Type II, second-degreee AV Block
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| *:* Asymptomatic Type I, second-degree AV Block (with wide complex)
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| * ''Class III''
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| *:* Asymptomatic Type I, second-degree AV block (with narrow complex)
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| ==ACC / AHA Guidelines- Recommendations for Acquired Atrioventricular Block in Adults (DO NOT EDIT) <ref name="Epstein"> Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM III, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices). Circulation. 2008; 117: 2820–2840. PMID 18483207 </ref>==
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| ===Class I===
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| 1. Permanent [[pacemaker]] implantation is indicated for [[third-degree AV block|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)''
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| 2. Permanent [[pacemaker]] implantation is indicated for [[third-degree AV block|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)''
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| 3. Permanent [[pacemaker]] implantation is indicated for [[third-degree AV block|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)''
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| 4. Permanent [[pacemaker]] implantation is indicated for [[third-degree AV block|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)''
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| 5. Permanent [[pacemaker]] implantation is indicated for [[third-degree AV block|third-degree]] and advanced [[second-degree AV block]] at any anatomic level after [[catheter ablation]] of the AV junction. ''(Level of Evidence: C)''
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| 6. Permanent [[pacemaker]] implantation is indicated for [[third-degree AV block|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)''
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| 7. Permanent [[pacemaker]] implantation is indicated for [[third-degree AV block|third-degree]] and advanced [[second-degree AV block]] at any anatomic level associated with [[neuromuscular disease]]s 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)''
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| 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)''
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| 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)''
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| 10. Permanent pacemaker implantation is indicated for [[second-degree AV block|second-]] or [[third-degree AV block]] during exercise in the absence of [[myocardial ischemia]]. ''(Level of Evidence: C)''
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| ===Class IIa===
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| 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)''
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| 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)''
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| 3. Permanent [[pacemaker]] implantation is reasonable for [[first-degree AV block|first-]] or [[second-degree AV block]] with symptoms similar to those of [[pacemaker syndrome]] or hemodynamic compromise. ''(Level of Evidence: B)''
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| 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)''
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| ===Class IIb===
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| 1. Permanent [[pacemaker]] implantation may be considered for [[neuromuscular disease]]s 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)''
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| 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)''
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| ===Class III===
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| 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.”)
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| 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)''
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| 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)''}}
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| ==Examples==
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| <div align="left">
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| <gallery heights="225" widths="225">
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| Image:LAE.jpg|First degree AV block is a misnomer in that every P wave is conducted to the ventricles, however, with a PR interval exceeding 200 msec. Prolonged PR conduction, a more appropriate classification for this conduction disturbance, may be the result of conduction delay within the atrium, AV node, bundle of His or bundle branches. Prolongation of the PR interval most often indicates AV nodal conduction delay.
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| Image:2to1AVBlock1.jpg|Two-to-one AV block can represent benign block within the AV node or disease of the His-Purkinje system. Certain electrocardiographic features and maneuvers can help in distinguishing where the location of block exists. A long PR interval with a narrow QRS suggests an intranodal block. A short PR interval with intraventricular conduction delay or bundle branch block suggests disease below the node. Responses to atropine, exercise and carotid sinus massage can be helpful in diagnosis. Atropine will improve AV nodal conduction but will worsen block within diseased His-Purkinje fibers. Exercise has a similar effect, improving conduction in cases where block exists only in the node, but worsening when block is subnodal. Alternatively, Carotid Sinus Massage will slow conduction when block occurs in the AV node, but will improve conduction in diseased His-Purkinje tissue by allowing for refractoriness to recover
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| </gallery>
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| </div>
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| ==Sources==
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| * The ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities <ref name="Epstein"> Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM III, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices). Circulation. 2008; 117: 2820–2840. PMID 18483207 </ref>
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| ==References==
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| {{Reflist|2}}
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| [[Category:Cardiology]] | | [[Category:Cardiology]] |
| [[Category:Electrophysiology]] | | [[Category:Electrophysiology]] |
| [[Category:Emergency medicine]]
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| [[Category:Disease]] | | [[Category:Disease]] |
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| {{WikiDoc Help Menu}}
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| {{WikiDoc Sources}}
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