Second degree AV block medical therapy: Difference between revisions
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*''' [[Atropine]]''' is a [[parasympatholytic]] [[drug]] that increase [[atrioventricular]] nodal conduction and [[automaticity]] when [[atrioventricular block]] is at the atrioventricular nodal level or [[bradycardia]] is related to excess [[vagal tone]]. | |||
* Dosage is 0.5- to 1.0-mg IV, may be repeated. | |||
* [[Atropine]] may enhance [[atrioventricular]] conduction in the setting of [[inferior MI]]. | |||
* For [[atrioventricular block]] at the level of [[His bundle]] or [[His-Purkinje]], [[atropine]] may worsen [[atrioventricular conduction]] or compromise [[hemodynamic]]. | |||
* Common adver effects of [[atropine]] include [[dry mouth]], [[blurred vision]], [[anhidrosis]], [[urinary retention]], and [[delirium]] , increased [[heart rate]] in the setting of [[MI]]. | |||
*'''[[Beta-adrenergic agonists]]''' such as [[isoproterenol]], [[dopamine]], [[dobutamine]], and [[epinephrine]] may have direct effect to increase [[ atrioventricular]] nodal and, to a lesser degree, [[His-Purkinje]] conduction. | |||
* The efficacy of [[dopamine]] was equal to [[transcutaneous pacing]] in 1 small randomized trial of [[patients]] with unstable [[bradycardia]] unresponsive to [[atropine]].<ref name="pmid5557475">{{cite journal |vauthors=Hatle L, Rokseth R |title=Conservative treatment of AV block in acute myocardial infarction. Results in 105 consecutive patients |journal=Br Heart J |volume=33 |issue=4 |pages=595–600 |date=July 1971 |pmid=5557475 |pmc=487219 |doi=10.1136/hrt.33.4.595 |url=}}</ref> | |||
*Common adverse effects of [[beta-adrenergic agonists]] may include [[ventricular arrhythmias]] , induction of [[coronary ischemia]], particularly in the setting of acute [[MI]]. | |||
*[[Isoproterenol]] because of the [[vasodilatory]] effects may exacerbate [[hypotension]]. | |||
*'''[[Aminophylline]]''' is a nonselective [[adenosine]] receptor antagonist and [[phosphodiesterase inhibitor]]. | |||
* Safety and efficacy of [[aminophylline]] for reversing [[bradycardia]] associated [[atrioventricular]] block in the setting of excess [[adnosine]] production in [[inferior MI]] was shown. <ref name="pmid17933452">{{cite journal |vauthors=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 |title=A randomized controlled feasibility trial comparing safety and effectiveness of prehospital pacing versus conventional treatment: 'PrePACE' |journal=Resuscitation |volume=76 |issue=3 |pages=341–9 |date=March 2008 |pmid=17933452 |pmc=7126680 |doi=10.1016/j.resuscitation.2007.08.008 |url=}}</ref> | |||
* There was no benefit for [[aminophylline]] in [[resuscitation]] for [[out-of-hospital]] brady-[[asystolic]] [[cardiac arrest]] based on a large randomized trial and a systematic review.<ref name="pmid26593309">{{cite journal |vauthors=Hurley KF, Magee K, Green R |title=Aminophylline for bradyasystolic cardiac arrest in adults |journal=Cochrane Database Syst Rev |volume= |issue=11 |pages=CD006781 |date=November 2015 |pmid=26593309 |doi=10.1002/14651858.CD006781.pub3 |url=}}</ref> | |||
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===Mobitz II=== | ===Mobitz II=== | ||
* Correction of reversible causes of the block such as [[ischemia]], [[medications]], and [[vagotonic]] [[conditions]] should be considered<ref name="pmid29850368">{{cite journal |vauthors=Li X, Xue Y, Wu H |title=A Case of Atrioventricular Block Potentially Associated with Right Coronary Artery Lesion and Ticagrelor Therapy Mediated by the Increasing Adenosine Plasma Concentration |journal=Case Rep Vasc Med |volume=2018 |issue= |pages=9385017 |date=2018 |pmid=29850368 |pmc=5933017 |doi=10.1155/2018/9385017 |url=}}</ref>. | * Correction of reversible causes of the block such as [[ischemia]], [[medications]], and [[vagotonic]] [[conditions]] should be considered.<ref name="pmid29850368">{{cite journal |vauthors=Li X, Xue Y, Wu H |title=A Case of Atrioventricular Block Potentially Associated with Right Coronary Artery Lesion and Ticagrelor Therapy Mediated by the Increasing Adenosine Plasma Concentration |journal=Case Rep Vasc Med |volume=2018 |issue= |pages=9385017 |date=2018 |pmid=29850368 |pmc=5933017 |doi=10.1155/2018/9385017 |url=}}</ref>. | ||
* [[Patients]] may need immediate transvenous pacing until a [[permanent pacemaker]] is placed<ref name="pmid29493981">{{cite journal |vauthors=Mangi MA, Jones WM, Mansour MK, Napier L |title= |journal= |volume= |issue= |pages= |date= |pmid=29493981 |doi= |url=}}</ref>. | * [[Patients]] may need immediate transvenous pacing until a [[permanent pacemaker]] is placed<ref name="pmid29493981">{{cite journal |vauthors=Mangi MA, Jones WM, Mansour MK, Napier L |title= |journal= |volume= |issue= |pages= |date= |pmid=29493981 |doi= |url=}}</ref>. | ||
* Treatment in emergency situations are [[atropine]] and an [[external pacer]].<ref name="pmid23224264">{{cite journal |vauthors=Barold SS, Herweg B |title=Second-degree atrioventricular block revisited |journal=Herzschrittmacherther Elektrophysiol |volume=23 |issue=4 |pages=296–304 |date=December 2012 |pmid=23224264 |doi=10.1007/s00399-012-0240-8 |url=}}</ref><ref name="pmid8445186">{{cite journal |vauthors=Wogan JM, Lowenstein SR, Gordon GS |title=Second-degree atrioventricular block: Mobitz type II |journal=J Emerg Med |volume=11 |issue=1 |pages=47–54 |date=1993 |pmid=8445186 |doi=10.1016/0736-4679(93)90009-v |url=}}</ref>. | * Treatment in emergency situations are [[atropine]] and an [[external pacer]].<ref name="pmid23224264">{{cite journal |vauthors=Barold SS, Herweg B |title=Second-degree atrioventricular block revisited |journal=Herzschrittmacherther Elektrophysiol |volume=23 |issue=4 |pages=296–304 |date=December 2012 |pmid=23224264 |doi=10.1007/s00399-012-0240-8 |url=}}</ref><ref name="pmid8445186">{{cite journal |vauthors=Wogan JM, Lowenstein SR, Gordon GS |title=Second-degree atrioventricular block: Mobitz type II |journal=J Emerg Med |volume=11 |issue=1 |pages=47–54 |date=1993 |pmid=8445186 |doi=10.1016/0736-4679(93)90009-v |url=}}</ref>. |
Revision as of 10:51, 11 July 2021
Second degree AV block Microchapters |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Salih, M.D. Cafer Zorkun, M.D., Ph.D. [2] Syed Musadiq Ali M.B.B.S.[3]
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 atropine. 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 rhythm often do not respond to atropineor beta-adrenergic agonists.
Medical Therapy
Recommendations for acute medical therapy for bradycardia associated atrioventricular block |
Medical therapy (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 |
Medical therapy (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 |
Medical therapy (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] |
---|
- Atropine is a parasympatholytic drug that increase atrioventricular nodal conduction and automaticity when atrioventricular block is at the atrioventricular nodal level or bradycardia is related to excess vagal tone.
- Dosage is 0.5- to 1.0-mg IV, may be repeated.
- Atropine may enhance atrioventricular conduction in the setting of inferior MI.
- For atrioventricular block at the level of His bundle or His-Purkinje, atropine may worsen atrioventricular conduction or compromise hemodynamic.
- Common adver effects of atropine include dry mouth, blurred vision, anhidrosis, urinary retention, and delirium , increased heart rate in the setting of MI.
- Beta-adrenergic agonists such as isoproterenol, dopamine, dobutamine, and epinephrine may have direct effect to increase atrioventricular nodal and, to a lesser degree, His-Purkinje conduction.
- The efficacy of dopamine was equal to transcutaneous pacing in 1 small randomized trial of patients with unstable bradycardia unresponsive to atropine.[2]
- Common adverse effects of beta-adrenergic agonists may include ventricular arrhythmias , induction of coronary ischemia, particularly in the setting of acute MI.
- Isoproterenol because of the vasodilatory effects may exacerbate hypotension.
- Aminophylline is a nonselective adenosine receptor antagonist and phosphodiesterase inhibitor.
- Safety and efficacy of aminophylline for reversing bradycardia associated atrioventricular block in the setting of excess adnosine production in inferior MI was shown. [3]
- There was no benefit for aminophylline in resuscitation for out-of-hospital brady-asystolic cardiac arrest based on a large randomized trial and a systematic review.[4]
Mobitz I
- Patients with type I second degree AV block are usually asymptomatic and do not require treatment.[5][6].
- Correction of reversible causes of the block such as ischemia, medications, and vagotonic conditions should be addressed[7].
- Atropine can be used in Type I second degree AV blocks with hypotension and bradycardia.
- Transvenous or transcutaneous Pacing may be needed to stabilize the patient when bradycardia is unresponsive to atropine.[5]
Mobitz II
- Correction of reversible causes of the block such as ischemia, medications, and vagotonic conditions should be considered.[8].
- Patients may need immediate transvenous pacing until a permanent pacemaker is placed[5].
- Treatment in emergency situations are atropine and an external pacer.[9][10].
References
- ↑ 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.
- ↑ 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.
- ↑ 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. - ↑ 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.
- ↑ 5.0 5.1 5.2 Mangi MA, Jones WM, Napier L. PMID 29493981. Missing or empty
|title=
(help) - ↑ 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.
- ↑ Kashou AH, Goyal A, Nguyen T, Chhabra L. PMID 29083636. Missing or empty
|title=
(help) - ↑ 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.
- ↑ 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.
- ↑ 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.