Heart block

Dr Praveen Gupta

05.12.2017

JIPMER

Pondicherry

India

CLT students class

1
 Atrioventricular block (heart block)

 An AV block exists if the atrial impulse is conducted with delay or is not conducted
at all to the ventricle when the AV junction is not physiologically refractory

 During AV block, block can occur in AV node, His bundle, or bundle branches

 Disturbance of impulse conduction that can be permanent or transient

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 Classified by severity into three categories

 First-degree heart block, conduction is prolonged but all impulses are conducted

 Second-degree heart block in two forms, Mobitz type I (Wenckebach) and type II

 Type I heart block is characterized by progressive lengthening of the conduction

time until an impulse is not conducted

 Type II heart block denotes an occasional or repetitive sudden block of conduction

of an impulse, without prior measurable lengthening of conduction time.

 When no impulses are conducted, complete or third-degree block

 Advanced or highgrade heart block,indicate blockage of two or more consecutive

impulses

Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 10th Edition, Chpater 37, Page no 792-95 3
 First-Degree Atrioventricular Block

 Every atrial impulse is conducted to the ventricles and a regular ventricular rate

 PR interval exceeds 0.20 second in adults.

 PR intervals can exceed the P-P interval, known as skipped P waves

 Result from a conduction delay in the AV node (A-H interval), in the His-Purkinje
system (H-V interval), or at both sites

 Equally delayed conduction over both bundle branches

 Intra-atrial conduction delay can result in PR prolongation

Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 10th Edition, Chpater 37, Page no 792-95 4
 First-Degree Atrioventricular Block

 QRS complex on the scalar ECG is normal, the AV delay in the AV node

 QRS complex shows a bundle branch block pattern, the conduction delay within the AV node
or the His-Purkinje system

 Acceleration of the atrial rate or enhancement of vagal tone by carotid massage cause first-
degree AV nodal block to progress to type I second-degree AV block

Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 10th Edition, Chpater 37, Page no 792-95 5
 Second-Degree Atrioventricular Block

 Blocking of some atrial impulses conducted to the ventricle

 Nonconducted P wave can be intermittent or frequent, occur at regular or irregular intervals,

and be preceded by fixed or lengthening PR intervals

 Type I second-degree AV block is characterized by progressive PR prolongation culminating

in a nonconducted P wave whereas in type II second-degree AV block, the PR interval

remains constant before the blocked P wave

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 3.2 AV block

© 01/12/2017, Department of cardiology, JIPMER, Pondicherry, India 7

 Second-Degree Atrioventricular Block
 AV block is intermittent and repetitive and can block several P waves in a row

 Mobitz type I and Mobitz type II are applied to the two types of block

 Wenckebach block refers to type I block only

 Type I conduction disturbance can be difficultm to recognize.

 During a typical type I block, the increment in conduction time is greatest in the second beat

of the Wenckebach group, and the absolute increase in conduction time decreases

progressively over subsequent beats.

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 2.1 AV block

© 2017, Department of cardiology, JIPMER, Pondicherry, India 9

 Characteristics of classic Wenckebach group beats

 Interval between successive beats progressively decreases, although conduction time

increases (but by a decreasing function)

 Duration of the pause produced by the nonconducted impulse is less than twice the interval

preceding the blocked impulse (which is usually the shortest interval)

 Cycle that follows nonconducted beat (beginning the Wenckebach group) is longer than cycle

preceding the blocked impulse

 Typical grouping occurs in < 50% of patients with a type I Wenckebach AV block

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 Differentiation of Type I from Type II
Atrioventricular Block

 A 2:1 AV block can be a form of type I or type II AV block

 If QRS is normal, block likely type I and in AV node, and search for transition of the 2:1

block to a 3:2 block, during which the PR interval lengthens in the second cardiac cycle

 If bundle branch block is present, block can be in AV node or His- Purkinje

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 Differentiation of Type I from Type II
Atrioventricular Block

 First-degree and type I second-degree AV block can occur in normal healthy children, and a

Wenckebach AV block normal in athletes due to increase in resting vagal tone

 In patients who have chronic second-degree AV nodal block (proximal to the His bundle)

without structural heart disease, the course is relatively benig, whereas in those with structural

heart disease, the prognosis is poor.

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 Third-Degree (Complete) Atrioventricular Block

 No atrial activity is conducted to the ventricles

 Atrial pacemaker can be sinus or ectopic (tachycardia, flutter, or fibrillation) or can

result from AV junctional focus above the block with retrograde atrial conduction

 Ventricular focus is located just below the region of the block, which can be above
or below the His bundle bifurcation.

 Ventricular pacemaker closer to the His bundle stable and faster escape rate than
can those located more distally in the conduction system.

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 Complete heart block

© 01/12/2017, Department of cardiology, JIPMER, Pondicherry, India 14

 Third-Degree (Complete) Atrioventricular Block

 Result from a block at AV node, bundle of His, Purkinje

 If block proximal to the His bundle, there will be normal QRS complexes at 40 to

60 beats/minute

 Intrahisian block poor prognosis

 Acquired complete AV block occurs most commonly distal to the bundle of His

because of trifascicular conduction disturbance.

 QRS complex is abnormal, and ventricular rate < 40 beats/minute

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 Third-Degree (Complete) Atrioventricular Block

 Paroxysmal AV block caused by vagotonic reflexes

 Surgery, electrolyte disturbances, myoendocarditis, tumors, Chagas disease,

rheumatoid nodules, calcific aortic stenosis, myxedema, polymyositis, infiltrative
processes (e.g., amyloidosis, sarcoidosis, scleroderma) can produce AV block

 Rapid rates sometimes followed by block (called tachycardia-dependent AV

block), which is thought to be due to a phase 3 block (block caused by incomplete
action potential recovery), postrepolarization refractoriness, and concealed
conduction in the AV node

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 Third-Degree (Complete) Atrioventricular Block

 Pause-dependent paroxysmal AV block results in AV block after a pause or during

relative bradycardia

 Referred to as a phase 4 block because it is thought that spontaneous

depolarizations during the resting phase of the action potential result in an inability

to depolarize,

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 Third-Degree (Complete) Atrioventricular Block

 In children AV block is congenital

 AV block can be an isolated finding or be associated with other lesions

 Neonatal autoimmune disease, account for most cases of heart block

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 Third-Degree (Complete) Atrioventricular Block

 Children are asymptomatic, some children, symptoms requiring pacemake

 Adams-Stokes attacks can occur

 Heart rate at rest 50 beats/minute or less correlates with the incidence of syncope

 Prolonged recovery times of escape foci after rapid pacing , slow heart rates on 24-hour

electrocardiographic recordings, and the occurrence of paroxysmal tachycardias may be

factors predisposing to the development of symptoms

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 Clinical Features

 First-degree AV block, long a to c wave interval in the jugular venous pulse

 Diminished first heart sound

 In type I second-degree AV block, the heart rate may increase imperceptibly with gradually
diminishing intensity of the first heart sound; widening of the a to c interval, terminated by a
pause; and an a wave not followed by a v wave.

 Intermittent ventricular pauses and a waves in the neck not followed by v waves characterize
type II AV block. First heart sound maintains a constant intensity

Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 10th Edition, Chpater 37, Page no 792-95 20
 Clinical Features

 In complete AV block, the findings are the same as those in AV dissociation

 Significant clinical manifestations of first- and second-degree AV block usually consist of

palpitations or subjective feelings of the heart “missing a beat.”

 Persistent 2:1 AV block can produce symptoms of chronic bradycardia

 Complete AV block can be accompanied by signs and symptoms of reduced cardiac output,

syncope or presyncope, angina, or palpitations from ventricular tachyarrhythmias

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 Management
 Holter or external loop recorders can be useful

 Longer periods of recording require an implantable loop recorder

 In patients with presyncope or syncope, one should suspect intermittent infra-His block in
those with bundle branch block or an intraventricular conduction defect.

 An EP study to thoroughly evaluate AV conduction (including infusion of isoproterenol

and/or procainamide) may be warranted to make the diagnosis, particularly in those with
severe symptoms

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 Management

 Drugs cannot be relied on to increase the heart rate

 Temporary or permanent pacemaker for symptomatic bradyarrhythmias.

 For short-term therapy, atropine are useful

 Isoproterenol can be used transiently

 Symptomatic AV block or high-grade AV block (e.g., infrahisian, type II AV block, third-

degree heart block not caused by congenital AV block), permanent pacemaker placement is
the treatment of choice.

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Thank you

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