Professional Documents
Culture Documents
Symptomatic Bradycardia
Defined as a documented bradyarrhythmia that is
directly responsible for development of:
Definite correlation of symptoms is required
clinical manifestations of syncope or near syncope
Transient dizziness or lightheadedness
Confusional states resulting from cerebral
hypoperfusion
Fatigue, exercise intolerance and congestive heart
failure
* Not to be confused with physiological sinus
bradycardia ( as occurs in highly trained athletes)
Bradycardias
Causes:
1.
2.
3.
Aortic stenosis
4.
5.
Hypothyroidism
6.
Physiological
7.
10
12
AV Block
First degree
Second degree
1.
2.
3.
Type I: Wenckebach
Mobitz II
2:1 (Blocking of 2 or more
consecutive P waves with
some conducted beats)
? Unequivocally type I or
type II
Width of QRS
AF: prolonged pause (>5s)
should be considered to be
advanced second degree AV
block
Anatomical:
Supra-His, Intra-His or Infra-His
Third degree
Absence of AV conduction
Chronic stable
Asystolic
13
Heart block
14
AV Block
First Degree AV Block
AV Block
Mobitz II
16
AV Block
2nd Degree - Mobitz II
AV Block
Class I
Third degree AV block and advanced second degree AV block at
any anatomic level associated with bradycardia with symptoms (
including heart failure) or ventricular arrhythmias presumed due
to AV block (C)
Associated with arrhythmias and other medical conditions that
require drug therapy that results in symptomatic bradycardia ( C)
In awake, symptom free pts in SR, documented peroids of
asystole 3.0 s or any escape rate 40 bpm or an escape rhythm
below the AV node ( C)
after catheter ablation of AV junction (C )
post-operative AV block that is not expected to resolve after
cardiac surgery ( C)
associated with neuro-muscular diseases 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 (B)
18
AV Block
Class I (continued)
High grade second degree AV block if symptomatic and
not reversible ( B )
Asymptomatic persistent third degree AV block at any
anatomic site with average awake V rate of 40 bpm or
faster if cardiomegaly or LV dysfunction is present or if
the site of block is below AV node (B)
Second and third-degree AV block during exercise in the
absence of myocardial ischemia (C)
AV Block
Class II a
Asymptomatic CHB (without cardiomegaly) of HR > 40 bpm (
C)
Class II b
Considered for neuromuscular diseases with any degree of AV
block (including First degree), with or without symptoms (B)
Unpredictable progression of AV conduction disease
AV block in setting of drug use and/or drug toxicity when block
is expected to recur even after the drug is withdrawn ( C)
20
AV Block
Class III
MARROW
23
WILLIAM
24
ESC Guideline
Definition
Permanent Pacing in
Chronic Bifascicular Block
In the presence of syncope, consideration for VT/VF
*These recommendations are consistent with the ACC/AHA Guidelines for the Management of Patients 27
with ST-Elevation Myocardial Infarction.
Role of EPS
1. Not indicated for bradycardia per se
2. Syncope of unknown origin + abnormal
SN function
3. HV>100ms in evaluation of syncope in
Chronic bifascicular block
4. Syncope + bifascicular block when VT
cannot be demonstrated [pacing may be
indicated even if HV<100 ms due to low
sensitivity of HV measurement (Class
IIa)]
30
Pacemaker/ICD/CRT
Method
In person
2-12 wk postimplantation
In person
In person or remote
In person or remote
In person
In person or remote
PERSISTENT BRADYCARDIA
Sinus node disease / Acquired AV block
INTERMITTENT DOCUMENTED
BRADYCARDIA
UNDOCUMENTED REFLEX
SYNCOPE
Management Consideration
Right Ventricular Pacing From Alternative Sites
Pacing from the right ventricle outflow tract is recognized as an
alternative to pacing from the apex. It does not lead to a greater
incidence of complications, although hemodynamic results an
depend on electrode location; para-Hisian pacing is more
favorable than medioseptal pacing
Management Consideration
Management Consideration
Temporary Transvenous Pacing
This is not recommended given the frequent associated
complications. If used, it should be for the minimum period and
PM implantation should take place as early as possible.