Paroxysmal AV Block Differential Diagnosis: Difference between revisions
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==Overview== | ==Overview== | ||
Considering that a number of conditions may present with a history of syncope and presyncope, paroxysmal AV block must treated as a diagnosis of exclusion. Vasaovagal syncope, situational syncope, carotid sinus hypersensitivity, seizures, structural heart defects such as aortic stenosis, hypertrophic cardiomyopathy and conduction defects such as atrial fibrillation, atrial flutter are a few conditions that need to be ruled out initially. | Considering that a number of conditions may present with a history of [[syncope]] and [[presyncope]], [[paroxysmal AV block]] must treated as a [[diagnosis]] of exclusion. [[Vasaovagal syncope]], [[situational syncope]], [[carotid sinus hypersensitivity]], [[Seizure|seizures]], structural heart defects such as [[aortic stenosis]], [[hypertrophic cardiomyopathy]] and [[Conduction System|conduction]] defects such as [[atrial fibrillation]], [[atrial flutter]] are a few [[conditions]] that need to be ruled out initially. | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Vasaovagal Syncope ]]''' | | style="padding: 5px 5px; background: #DCDCDC;" | '''[[Vasaovagal Syncope ]]''' | ||
| style="padding: 5px 5px; background: #F5F5F5;" | Occurs secondary to emotional distress, prolonged standing, painful stimuli. Seen more in women and may be diagnosed by tilt table testing. Not associated with periods of asystole. | | style="padding: 5px 5px; background: #F5F5F5;" | Occurs [[secondary]] to [[emotional]] distress, [[prolonged]] standing, [[painful]] [[stimuli]]. Seen more in women and may be [[diagnosed]] by [[Tilt table test|tilt table testing]]. Not associated with periods of [[asystole]]. | ||
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| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Situational Syncope ]]''' | | style="padding: 5px 5px; background: #DCDCDC;" | '''[[Situational Syncope ]]''' | ||
| style="padding: 5px 5px; background: #F5F5F5;" | Due to cardioinhibitory and vasopressor mechanisms. Syncope may be associated with cough, micturition and defecation. Not associated with periods of asystole. | | style="padding: 5px 5px; background: #F5F5F5;" | Due to [[cardioinhibitory]] and [[vasopressor]] mechanisms. [[Syncope]] may be associated with [[cough]], [[micturition]] and [[defecation]]. Not associated with periods of [[asystole]]. | ||
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| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Carotid Sinus hypersensitivity]]''' | | style="padding: 5px 5px; background: #DCDCDC;" | '''[[Carotid Sinus hypersensitivity]]''' | ||
| style="padding: 5px 5px; background: #F5F5F5;" | Common causes of unexplained syncope in individuals more than 40 years of age. Syncope may be associated with wearing shirts with tight collars. Not associated with periods of asystole. | | style="padding: 5px 5px; background: #F5F5F5;" | Common causes of unexplained [[syncope]] in individuals more than 40 years of age. [[Syncope]] may be associated with wearing shirts with tight collars. Not associated with periods of [[asystole]]. | ||
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| style="padding: 5px 5px; background: #DCDCDC;" |'''[[Aortic Stenosis ]]''' | | style="padding: 5px 5px; background: #DCDCDC;" |'''[[Aortic Stenosis ]]''' | ||
| style="padding: 5px 5px; background: #F5F5F5;" |Presents with syncope, angina and dyspnea on exertion. Not associated with periods of asystole but may show features of left ventricular hypertrophy. On Physical examination,pulsus parvus et tardus may be noted and a systolic click followed by a crescendo decrescendo murmur may be heard over the aortic area. | | style="padding: 5px 5px; background: #F5F5F5;" |Presents with [[syncope]], [[angina]] and [[dyspnea]] on exertion. Not associated with periods of [[asystole]] but may show features of [[left ventricular hypertrophy]]. On Physical examination,[[pulsus parvus et tardus]] may be noted and a [[Systolic click—murmur syndrome|systolic click]] followed by a [[Crescendo decrescendo|crescendo decrescendo murmur]] may be heard over the [[aortic]] area. | ||
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| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Hypertrophic Cardiomyopathy ]]''' | | style="padding: 5px 5px; background: #DCDCDC;" | '''[[Hypertrophic Cardiomyopathy ]]''' | ||
| style="padding: 5px 5px; background: #F5F5F5;" | | | style="padding: 5px 5px; background: #F5F5F5;" |Common cause of [[sudden cardiac death]] in adolescents during [[physical]] activity. Family history is often present. Not associated with periods of [[asystole]]. | ||
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| style="padding: 5px 5px; background: #DCDCDC;" | '''[[1st Degree AV Block ]]''' | | style="padding: 5px 5px; background: #DCDCDC;" | '''[[1st Degree AV Block ]]''' | ||
| style="padding: 5px 5px; background: #F5F5F5;" | P waves associated with 1:1 atrioventricular conduction and a PR interval >200 ms (this is more accurately defined as atrioventricular delay because no P waves are blocked) | | style="padding: 5px 5px; background: #F5F5F5;" |[[P wave|P waves]] associated with 1:1 [[Atrioventricular|atrioventricular conduction]] and a [[PR interval]] >200 ms (this is more accurately defined as [[atrioventricular]] delay because no [[P wave|P waves]] are blocked) | ||
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| style="padding: 5px 5px; background: #DCDCDC;" | '''[[2nd Degree AV Block]]''' | | style="padding: 5px 5px; background: #DCDCDC;" | '''[[2nd Degree AV Block]]''' | ||
| style="padding: 5px 5px; background: #F5F5F5;" | | | style="padding: 5px 5px; background: #F5F5F5;" |[[P wave|P waves]] with a constant [[rate]] (<100 bpm) where [[atrioventricular]] conduction is present but not 1:1. '''[[Mobitz Type 1]]''': [[P wave|P waves]] with a constant [[rate]] (<100 bpm) with a periodic single nonconducted [[P wave]] associated with [[P wave|P waves]] before and after the nonconducted [[P wave]] with inconstant PR intervals. '''Mobitz Type 2''' : [[P wave|P waves]] with a constant [[rate]] (< 100 bpm) with a periodic single nonconducted [[P wave]] associated with other [[P wave|P waves]] before and after the nonconducted [[P wave]] with constant [[PR interval|PR intervals]] (excluding 2:1 [[atrioventricular]] block) <ref name="pmid30412710">{{cite journal| author=Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR | display-authors=etal| title=2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. | journal=J Am Coll Cardiol | year= 2019 | volume= 74 | issue= 7 | pages= 932-987 | pmid=30412710 | doi=10.1016/j.jacc.2018.10.043 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30412710 }} </ref> | ||
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| style="padding: 5px 5px; background: #DCDCDC;" | '''[[3rd Degree AV Block]]''' | | style="padding: 5px 5px; background: #DCDCDC;" | '''[[3rd Degree AV Block]]''' | ||
| style="padding: 5px 5px; background: #F5F5F5;" | No evidence of atrioventricular conduction. <ref name="pmid30412710">{{cite journal| author=Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR | display-authors=etal| title=2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. | journal=J Am Coll Cardiol | year= 2019 | volume= 74 | issue= 7 | pages= 932-987 | pmid=30412710 | doi=10.1016/j.jacc.2018.10.043 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30412710 }} </ref> | | style="padding: 5px 5px; background: #F5F5F5;" | No evidence of [[atrioventricular]] conduction. <ref name="pmid30412710">{{cite journal| author=Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR | display-authors=etal| title=2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. | journal=J Am Coll Cardiol | year= 2019 | volume= 74 | issue= 7 | pages= 932-987 | pmid=30412710 | doi=10.1016/j.jacc.2018.10.043 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30412710 }} </ref> | ||
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| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Atrial Fibrillation]]''' | | style="padding: 5px 5px; background: #DCDCDC;" | '''[[Atrial Fibrillation]]''' | ||
| style="padding: 5px 5px; background: #F5F5F5;" | May present with syncope, presyncope, lightheadedness or palpitations. Associated with irregular RR intervals and absence of clearly defined P waves. | | style="padding: 5px 5px; background: #F5F5F5;" | May present with [[syncope]], [[presyncope]], [[lightheadedness]] or [[Palpitation|palpitations]]. Associated with irregular [[RR intervals]] and absence of clearly defined [[P wave|P waves]]. | ||
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| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Congenital long QT syndrome/ Torsade de pointes ]]''' | | style="padding: 5px 5px; background: #DCDCDC;" | '''[[Congenital long QT syndrome|Congenital long QT syndrome/ Torsade de pointes]] ''' | ||
| style="padding: 5px 5px; background: #F5F5F5;" | Associated with electrolyte abnormalities such as hypokalemia, hypomagnesemia, hypocalcemia or congenital conditions such as Jervell- Lange- Nielsen Syndrome and Romano | | style="padding: 5px 5px; background: #F5F5F5;" | Associated with [[electrolyte]] abnormalities such as [[hypokalemia]], [[hypomagnesemia]], [[hypocalcemia]] or [[congenital]] conditions such as [[Jervell- Lange- Nielsen Syndrome]] and [[Romano Ward Syndrome]] which may degenerate into a life threatening [[polymorphic ventricular tachycardia]]. | ||
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| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Seizures]]''' | | style="padding: 5px 5px; background: #DCDCDC;" | '''[[Seizures]]''' | ||
| style="padding: 5px 5px; background: #F5F5F5;" | May be associated with generalized tonic clonic movements, tongue bite, bowel or bladder incontinence, a post ictal state and Todd’s paralysis. Following a loss of consciousness, there is a delayed recovery time. | | style="padding: 5px 5px; background: #F5F5F5;" | May be associated with generalized [[tonic clonic]] movements, [[tongue]] bite, [[bowel]] or [[bladder]] incontinence, a [[Postictal state|post ictal state]] and [[Todd’s paralysis]]. Following a loss of [[consciousness]], there is a delayed [[recovery]] time. | ||
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| style="padding: 5px 5px; background: #DCDCDC;" | '''Others''' | | style="padding: 5px 5px; background: #DCDCDC;" | '''Others''' | ||
| style="padding: 5px 5px; background: #F5F5F5;" | Atrial Flutter,Subclavian Steal syndrome, Vertebrobasilar Transient Ischemic Attacks, Sick Sinus Syndrome, Psychogenic Pseudosyncope, Psychogenic Non epileptic Seizures. | | style="padding: 5px 5px; background: #F5F5F5;" |[[Atrial flutter|Atrial Flutter]],[[Subclavian Steal syndrome]], [[Transient Ischemic Attacks|Vertebrobasilar Transient Ischemic Attacks]], [[Sick sinus syndrome|Sick Sinus Syndrome]], [[Psychogenic Pseudosyncope]], [[Psychogenic Non epileptic Seizures]]. | ||
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==References== | ==References== | ||
<references /> | |||
Revision as of 10:10, 26 June 2020
Overview
Considering that a number of conditions may present with a history of syncope and presyncope, paroxysmal AV block must treated as a diagnosis of exclusion. Vasaovagal syncope, situational syncope, carotid sinus hypersensitivity, seizures, structural heart defects such as aortic stenosis, hypertrophic cardiomyopathy and conduction defects such as atrial fibrillation, atrial flutter are a few conditions that need to be ruled out initially.
Differential Diagnosis
| Disease | Findings |
|---|---|
| Vasaovagal Syncope | Occurs secondary to emotional distress, prolonged standing, painful stimuli. Seen more in women and may be diagnosed by tilt table testing. Not associated with periods of asystole. |
| Situational Syncope | Due to cardioinhibitory and vasopressor mechanisms. Syncope may be associated with cough, micturition and defecation. Not associated with periods of asystole. |
| Carotid Sinus hypersensitivity | Common causes of unexplained syncope in individuals more than 40 years of age. Syncope may be associated with wearing shirts with tight collars. Not associated with periods of asystole. |
| Aortic Stenosis | Presents with syncope, angina and dyspnea on exertion. Not associated with periods of asystole but may show features of left ventricular hypertrophy. On Physical examination,pulsus parvus et tardus may be noted and a systolic click followed by a crescendo decrescendo murmur may be heard over the aortic area. |
| Hypertrophic Cardiomyopathy | Common cause of sudden cardiac death in adolescents during physical activity. Family history is often present. Not associated with periods of asystole. |
| 1st Degree AV Block | P waves associated with 1:1 atrioventricular conduction and a PR interval >200 ms (this is more accurately defined as atrioventricular delay because no P waves are blocked) |
| 2nd Degree AV Block | P waves with a constant rate (<100 bpm) where atrioventricular conduction is present but not 1:1. Mobitz Type 1: P waves with a constant rate (<100 bpm) with a periodic single nonconducted P wave associated with P waves before and after the nonconducted P wave with inconstant PR intervals. Mobitz Type 2 : P waves with a constant rate (< 100 bpm) with a periodic single nonconducted P wave associated with other P waves before and after the nonconducted P wave with constant PR intervals (excluding 2:1 atrioventricular block) [1] |
| 3rd Degree AV Block | No evidence of atrioventricular conduction. [1] |
| Atrial Fibrillation | May present with syncope, presyncope, lightheadedness or palpitations. Associated with irregular RR intervals and absence of clearly defined P waves. |
| Congenital long QT syndrome/ Torsade de pointes | Associated with electrolyte abnormalities such as hypokalemia, hypomagnesemia, hypocalcemia or congenital conditions such as Jervell- Lange- Nielsen Syndrome and Romano Ward Syndrome which may degenerate into a life threatening polymorphic ventricular tachycardia. |
| Seizures | May be associated with generalized tonic clonic movements, tongue bite, bowel or bladder incontinence, a post ictal state and Todd’s paralysis. Following a loss of consciousness, there is a delayed recovery time. |
| Others | Atrial Flutter,Subclavian Steal syndrome, Vertebrobasilar Transient Ischemic Attacks, Sick Sinus Syndrome, Psychogenic Pseudosyncope, Psychogenic Non epileptic Seizures. |
"ESC Guidelines on Syncope (Diagnosis and Management of)".
References
- ↑ 1.0 1.1 Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR; et al. (2019). "2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society". J Am Coll Cardiol. 74 (7): 932–987. doi:10.1016/j.jacc.2018.10.043. PMID 30412710.