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JACC: CLINICAL ELECTROPHYSIOLOGY VOL. 1, NO.

6, 2015

ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 2405-500X/$36.00

PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacep.2015.09.005

EDITORIAL COMMENT

Complete Heart Block Complicating


ST-Segment Elevation Myocardial
Infarction Has Not Gone Away*
Andrew E. Epstein, MD

D espite marked improvements in the man-


agement of acute coronary syndromes,
complete atrioventricular (AV) block can
still complicate acute myocardial infarction (MI) (1).
outcomes and the temporal trends and incidence of
CHB complicating acute ST-segment
myocardial infarction (STEMI) in the current era.
Using data from the National Inpatient Sample for
elevation

In the pre-thrombolytic era, second- or third-degree 2003 to 2012, of 2,273,853 patients with STEMI,
AV block was recorded in 5% to 7% of patients pre- 49,882 (2.2%) had CHB. The incidence of CHB
senting with acute MI (2,3), and reached 28% in those increased from 2.1% in 2003 to 2.3% in 2012 (adjusted
with inferior MI (4). In the thrombolytic era, Meine OR per year: 1.02; 95% CI: 1.01 to 1.03). In-hospital
et al. (5) reported that the overall incidence was little mortality was higher in those with than in those
changed at 6.9% with inferior MI; age, worse Killip without CHB (20.4% vs. 8.7%, respectively). Although
class at presentation, female sex, smoking, hyperten- the association was independent of the location of
sion, and diabetes were all risk factors for its occur- STEMI, the association was the greatest in patients
rence. In that study, adjusted 1-year mortality was with anterior STEMI. Interestingly, the rate of per-
significantly higher in patients with than in those manent pacemaker (PPM) implantation declined
without AV block (odds ratio [OR]: 1.5; 95% confi- (adjusted OR per year: 0.96), and in-hospital mortal-
dence interval [CI]: 1.3 to 1.6), and when subdivided ity remained unchanged during the study period. As
by location, the ORs for death were 2.4 (95% CI: 2.2 expected, the rate of PPM implantation was lower for
to 2.6) and 3.3 (95% CI: 3.0 to 3.7) for inferior and patients with CHB complicating inferior MI compared
anterior MI, respectively. One problem with both with anterior MI.
older and more recent data is that a distinction is Why is CHB with STEMI increasing when cardiac
not made between second- and third-degree AV care has improved and mortality decreased (7)? There
block. are several possible explanations. First, the time
point of reference must be considered: despite the
SEE PAGE 529
increasing trend of CHB in the current study, the rate
In this issue of JACC: Clinical Electrophysiology, is still much less than that in the pre-thrombolytic era
Harikrishnan et al. (6) examine the association of (3–5,8), and as discussed by Harikrishnan et al. (6),
third degree or complete heart block (CHB) with this likely reflects overall improvement in MI care.
Second, if patients are now seeking care and being
treated earlier after symptoms develop, they may
*Editorials published in JACC: Clinical Electrophysiology reflect the views
present with acute coronary syndromes or non-STEMI
of the authors and do not necessarily represent the views of JACC: rather than STEMI. Thus, those with STEMI may be
Clinical Electrophysiology or the American College of Cardiology. sicker and more likely to have an arrhythmia or other
From the Electrophysiology Section, Division of Cardiovascular Medicine, complication in their hospital course. As a conse-
University of Pennsylvania, Philadelphia, Pennsylvania. Dr. Epstein has quence, when those “late presenters” develop CHB, it
received research grants from Biotronik, Boston Scientific, and St. Jude
is in combination with greater myocardial damage
Medical; and has received honoraria for committee membership and
fellowship support from Boston Scientific, Medtronic, and St. Jude that may lead to more serious consequences. In
Medical. keeping with this hypothesis, in the current study,
540 Epstein JACC: CLINICAL ELECTROPHYSIOLOGY VOL. 1, NO. 6, 2015

Complete Heart Block Complicating STEMI DECEMBER 2015:539–41

compared with STEMI patients without CHB, those years of the current study included years during
with CHB were older and had more underlying which it became known that the Department of Jus-
comorbidities. Third, the definition of MI has under- tice (DOJ) was investigating inappropriate ICD im-
gone evolution. It is possible that with changes in plantation, with a focus on implantation of these
definition, patients identified as having STEMI or devices before expiration of a waiting period of
non-STEMI may have been different depending on 1 month if no revascularization had been undertaken
the definition in use at the time of presentation. or 3 months if there was revascularization (10).
Notably in the current study, the investigators point These waiting periods were and are mandated by both
out that the National Inpatient Sample from which the American College of Cardiology/American Heart
their data were derived redesigned its structure dur- Society/Heart Rhythm Society device-based therapy
ing the study to reduce errors in classification and guideline (11) and the National Coverage Determina-
improve statistical estimations. In addition, they tion (NCD) (12), of which the latter is the legal basis of
point out that hospital documentation may have reimbursement eligibility for ICD implantation (for
evolved to maximize reimbursement, leading to an both hospitals and providers) by Medicare/Centers for
artificial increase in the incidence of CHB. In short, Medicare & Medicaid Services (CMS). These docu-
the classification of STEMI was not static during the ments are based on the results of well-done ran-
years the study was done. domized, controlled clinical trials. Importantly, there
This study led me to think about several related are no data that support early ICD implantation to
issues. The investigators did not provide information improve outcomes (13,14). However, for the patient
about the prediction of CHB in patients who present with CHB post-MI, implanting a PPM is not elective
with first- or second-degree AV block, right or left and cannot wait. It is conceivable that cognizance or
bundle branch block, with or without a hemiblock, or a fear of the Department of Justice investigation influ-
combination of these. Melgarejo-Moreno et al. (9) re- enced the balance of PPMs versus ICDs implanted for
ported that in the thrombolytic era, right bundle CHB complicating MI confounded the National Inpa-
branch block complicating acute MI remained predic- tient Sample data. Although we now have Appro-
tive of mortality, but that it was associated with a priate Use Criteria that list scenarios in which an ICD
lower rate of bifasicular block, possibly representing can be implanted within the waiting period (e.g., CHB
a beneficial effect of thrombolysis. For those with complicating STEMI), these criteria were published in
second- or third-degree AV block post-MI, what is the 2013, after the study ended (15). Even with this
time course of progressing from some AV or intraven- document, providers are still left with the uncom-
tricular conduction disturbance to complete AV block? fortable understanding that CMS coverage for im-
How long should patients be monitored in the hospital plantation is not assured because the NCD has never
or intensive care unit? Is there a group who should been updated. Although we might find comfort that
be monitored after discharge if they had CHB that there is now precedent that in the DOJ inquiry phy-
resolved and no PPM was implanted, or had a transient sicians who implanted a device in patients such as
or persistent conduction disturbance? We have no previously described were not cited for false claims
answers to these important clinical questions. (16), the so-called resolution model does not consti-
Second, although the numbers reported in this tute policy for the future. We need an updated NCD in
study are statistically significant, are they clinically which situations like this are addressed so that any
so? Yes, the percentage of patients with STEMI ambiguity regarding appropriate patient management
developing CHB increased 0.2% over a decade, and as is removed.
discussed previously, the reasons for that are likely Because CHB has not gone away, Harikrishan et al.
more related to behavior and definition, rather than (6) have given us new information, food for thought,
something intrinsically different about MI now for which we should be grateful. In the “old days” it
compared with previous years. However, I do not was said that although patients with inferior MI who
think we are going to change our practice of developed AV block had poor in-hospital outcomes,
implanting pacemakers in patients with CHB after long-term prognosis was similar irrespective of its
STEMI (or non-STEMI), especially if it is anterior. occurrence (17), even for those with CHB (18). How-
They will be will receive pacemakers. ever, patients with anterior MI and CHB did not fare
A third point for discussion is that because CHB as well in the past (3), or today as in the current study.
continues to be a problem, how should it be managed As the investigators point out, CHB with STEMI was
in an era when implantable cardioverter-defibrillators associated with a 20.4% increase in mortality, twice
(ICDs) are recommended for survivors of MI who have that seen in patients without CHB. New initiatives can
persistent left ventricular dysfunction? The later be envisioned to identify high-risk subsets with a
JACC: CLINICAL ELECTROPHYSIOLOGY VOL. 1, NO. 6, 2015 Epstein 541
DECEMBER 2015:539–41 Complete Heart Block Complicating STEMI

high risk for CHB and prophylactically treat those requirement for pacing? Might stem cell therapy be
patients to protect the AV conduction system. For useful in the acute or chronic setting? We also need to
those who require pacing, would His bundle pacing, be at the table if and when the NCD is updated to
when feasible, be beneficial? Unfortunately, for ensure that the majority of patients with pacing and
anterior MI complicated by CHB, this may be pre- ICD indications are covered without fear of nonpay-
cluded because the level of AV block is more likely to ment or legal reprimand. The investigators of this
be distal in the His-Purkinje system than at the AV study should be commended for reminding us of our
node. Would septal pacing be better than apical pac- humility, the enduring problem of (complete) heart
ing, and does the MI location matter? How could block in STEMI, and how future therapies may
biventricular pacing be applied in this population? further affect a distressing and persistently high
For patients with large MIs and no indication for mortality.
pacing, biventricular pacing was anticipated to hold
promise (19), but larger trials did not show improved REPRINT REQUESTS AND CORRESPONDENCE: Dr.
remodeling (20,21) or quality of live, functional class, Andrew E. Epstein, Electrophysiology Section, Divi-
rate of hospitalization, or mortality (21) even when sion of Cardiovascular Medicine, University of Penn-
peri-infarct locations were targeted for lead place- sylvania, 3400 Spruce Street, 9 Founders Pavilion,
ment. Would the outcome be different if biventricular Philadelphia, Pennsylvania 19104. E-mail: andrew.
pacing was done for patients post-MI who have a epstein@uphs.upenn.edu.

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