JACC: CLINICAL ELECTROPHYSIOLOGY
6, 2015
ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
PUBLISHED BY ELSEVIER INC.
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).
In the pre-thrombolytic era, second- or third-degree
AV block was recorded in 5% to 7% of patients pre-
senting with acute MI (2,3), and reached 28% in those
with inferior MI (4). In the thrombolytic era, Meine
et al. (5) reported that the overall incidence was little
changed at 6.9% with inferior MI; age, worse Killip
class at presentation, female sex, smoking, hyperten-
sion, and diabetes were all risk factors for its occur-
rence. In that study, adjusted 1-year mortality was
significantly higher in patients with than in those
without AV block (odds ratio [OR]: 1.5; 95% confi-
dence interval [CI]: 1.3 to 1.6), and when subdivided
by location, the ORs for death were 2.4 (95% CI: 2.2
to 2.6) and 3.3 (95% CI: 3.0 to 3.7) for inferior and
anterior MI, respectively. One problem with both
older and more recent data is that a distinction is
not made between second- and third-degree AV
block.
SEE PAGE 529
In this issue of JACC: Clinical Electrophysiology,
Harikrishnan et al. (6) examine the association of
third degree or complete heart block (CHB) with
*Editorials published in JACC: Clinical Electrophysiology reflect the views
of the authors and do not necessarily represent the views of JACC:
Clinical Electrophysiology or the American College of Cardiology.
From the Electrophysiology Section, Division of Cardiovascular Medicine,
University of Pennsylvania, Philadelphia, Pennsylvania. Dr. Epstein has
received research grants from Biotronik, Boston Scientific, and St. Jude
Medical; and has received honoraria for committee membership and
fellowship support from Boston Scientific, Medtronic, and St. Jude
Medical.
VOL. 1, NO.
ISSN 2405-500X/$36.00
http://dx.doi.org/10.1016/j.jacep.2015.09.005
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
2003 to 2012, of 2,273,853 patients with STEMI,
49,882 (2.2%) had CHB. The incidence of CHB
increased from 2.1% in 2003 to 2.3% in 2012 (adjusted
OR per year: 1.02; 95% CI: 1.01 to 1.03). In-hospital
mortality was higher in those with than in those
without CHB (20.4% vs. 8.7%, respectively). Although
the association was independent of the location of
STEMI, the association was the greatest in patients
with anterior STEMI. Interestingly, the rate of per-
manent pacemaker (PPM) implantation declined
(adjusted OR per year: 0.96), and in-hospital mortal-
ity remained unchanged during the study period. As
expected, the rate of PPM implantation was lower for
patients with CHB complicating inferior MI compared
with anterior MI.
Why is CHB with STEMI increasing when cardiac
care has improved and mortality decreased (7)? There
are several possible explanations. First, the time
point of reference must be considered: despite the
increasing trend of CHB in the current study, the rate
is still much less than that in the pre-thrombolytic era
(3–5,8), and as discussed by Harikrishnan et al. (6),
this likely reflects overall improvement in MI care.
Second, if patients are now seeking care and being
treated earlier after symptoms develop, they may
present with acute coronary syndromes or non-STEMI
rather than STEMI. Thus, those with STEMI may be
sicker and more likely to have an arrhythmia or other
complication in their hospital course. As a conse-
quence, when those “late presenters” develop CHB, it
is in combination with greater myocardial damage
that may lead to more serious consequences. In
keeping with this hypothesis, in the current study,
540 Epstein
Complete Heart Block Complicating STEMI
compared with STEMI patients without CHB, those
with CHB were older and had more underlying
comorbidities. Third, the definition of MI has under-
gone evolution. It is possible that with changes in
definition, patients identified as having STEMI or
non-STEMI may have been different depending on
the definition in use at the time of presentation.
Notably in the current study, the investigators point
out that the National Inpatient Sample from which
their data were derived redesigned its structure dur-
ing the study to reduce errors in classification and
improve statistical estimations. In addition, they
point out that hospital documentation may have
evolved to maximize reimbursement, leading to an
artificial increase in the incidence of CHB. In short,
the classification of STEMI was not static during the
years the study was done.
This study led me to think about several related
issues. The investigators did not provide information
about the prediction of CHB in patients who present
with first- or second-degree AV block, right or left
bundle branch block, with or without a hemiblock, or a
combination of these. Melgarejo-Moreno et al. (9) re-
ported that in the thrombolytic era, right bundle
branch block complicating acute MI remained predic-
tive of mortality, but that it was associated with a
lower rate of bifasicular block, possibly representing
a beneficial effect of thrombolysis. For those with
second- or third-degree AV block post-MI, what is the
time course of progressing from some AV or intraven-
tricular conduction disturbance to complete AV block?
How long should patients be monitored in the hospital
or intensive care unit? Is there a group who should
be monitored after discharge if they had CHB that
resolved and no PPM was implanted, or had a transient
or persistent conduction disturbance? We have no
answers to these important clinical questions.
Second, although the numbers reported in this
study are statistically significant, are they clinically
so? Yes, the percentage of patients with STEMI
developing CHB increased 0.2% over a decade, and as
discussed previously, the reasons for that are likely
more related to behavior and definition, rather than
something intrinsically different about MI now
compared with previous years. However, I do not
think we are going to change our practice of
implanting pacemakers in patients with CHB after
STEMI (or non-STEMI), especially if it is anterior.
They will be will receive pacemakers.
A third point for discussion is that because CHB
continues to be a problem, how should it be managed
in an era when implantable cardioverter-defibrillators
(ICDs) are recommended for survivors of MI who have
persistent left ventricular dysfunction? The later
JACC: CLINICAL ELECTROPHYSIOLOGY VOL. 1, NO. 6, 2015
DECEMBER 2015:539–41
years of the current study included years during
which it became known that the Department of Jus-
tice (DOJ) was investigating inappropriate ICD im-
plantation, with a focus on implantation of these
devices before expiration of a waiting period of
1 month if no revascularization had been undertaken
or 3 months if there was revascularization (10).
These waiting periods were and are mandated by both
the American College of Cardiology/American Heart
Society/Heart Rhythm Society device-based therapy
guideline (11) and the National Coverage Determina-
tion (NCD) (12), of which the latter is the legal basis of
reimbursement eligibility for ICD implantation (for
both hospitals and providers) by Medicare/Centers for
Medicare & Medicaid Services (CMS). These docu-
ments are based on the results of well-done ran-
domized, controlled clinical trials. Importantly, there
are no data that support early ICD implantation to
improve outcomes (13,14). However, for the patient
with CHB post-MI, implanting a PPM is not elective
and cannot wait. It is conceivable that cognizance or
fear of the Department of Justice investigation influ-
enced the balance of PPMs versus ICDs implanted for
CHB complicating MI confounded the National Inpa-
tient Sample data. Although we now have Appro-
priate Use Criteria that list scenarios in which an ICD
can be implanted within the waiting period (e.g., CHB
complicating STEMI), these criteria were published in
2013, after the study ended (15). Even with this
document, providers are still left with the uncom-
fortable understanding that CMS coverage for im-
plantation is not assured because the NCD has never
been updated. Although we might find comfort that
there is now precedent that in the DOJ inquiry phy-
sicians who implanted a device in patients such as
previously described were not cited for false claims
(16), the so-called resolution model does not consti-
tute policy for the future. We need an updated NCD in
which situations like this are addressed so that any
ambiguity regarding appropriate patient management
is removed.
Because CHB has not gone away, Harikrishan et al.
(6) have given us new information, food for thought,
for which we should be grateful. In the “old days” it
was said that although patients with inferior MI who
developed AV block had poor in-hospital outcomes,
long-term prognosis was similar irrespective of its
occurrence (17), even for those with CHB (18). How-
ever, patients with anterior MI and CHB did not fare
as well in the past (3), or today as in the current study.
As the investigators point out, CHB with STEMI was
associated with a 20.4% increase in mortality, twice
that seen in patients without CHB. New initiatives can
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
patients to protect the AV conduction system. For
those who require pacing, would His bundle pacing,
when feasible, be beneficial? Unfortunately, for
anterior MI complicated by CHB, this may be pre-
cluded because the level of AV block is more likely to
be distal in the His-Purkinje system than at the AV
node. Would septal pacing be better than apical pac-
ing, and does the MI location matter? How could
biventricular pacing be applied in this population?
For patients with large MIs and no indication for
pacing, biventricular pacing was anticipated to hold
promise (19), but larger trials did not show improved
remodeling (20,21) or quality of live, functional class,
rate of hospitalization, or mortality (21) even when
peri-infarct locations were targeted for lead place-
ment. Would the outcome be different if biventricular
pacing was done for patients post-MI who have a
requirement for pacing? Might stem cell therapy be
useful in the acute or chronic setting? We also need to
be at the table if and when the NCD is updated to
ensure that the majority of patients with pacing and
ICD indications are covered without fear of nonpay-
ment or legal reprimand. The investigators of this
study should be commended for reminding us of our
humility, the enduring problem of (complete) heart
block in STEMI, and how future therapies may
further affect a distressing and persistently high
mortality.
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
Andrew E. Epstein, Electrophysiology Section, Divi-
sion of Cardiovascular Medicine, University of Penn-
sylvania, 3400 Spruce Street, 9 Founders Pavilion,
Philadelphia, Pennsylvania 19104. E-mail: andrew.
epstein@uphs.upenn.edu.

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KEY WORDS heart block,
myocardial infarction, pacemaker