Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
DR AHMAD USMAN
CONSULTANT INTERVENTIONAL CARDIOLOGIST
OBJECTIVES
• Review heart blocks, their clinical significance and
management
• Provide an overview of pacemaker components,
nomenclature and functions
• Discuss complications of pacemaker implantation
• Talk about pacemaker malfunction
• Touch on ED management and disposition of pacemaker
patients
• Offer a precis of temporary pacing modalities.
• ICDs not covered in this talk.
CASE
• Vitals:
• HR 45, regular
• RR 16
• BP 108/75
• 02 sats 97% on RA
• Afebrile
Granny’s ECG
ATRIOVENTRICULAR BLOCKS
• Definition:
• Delay or interruption in the transmission of an impulse from the
atria to the ventricles
• Conduction may be delayed, intermittent or absent.
• Duration
• Transient
• Permanent
• Causes may be:
• Anatomical
• Functional
ETIOLOGY
• Vasovagal
• Pain
• Occulocardiac reflex
• Diving reflex
• Carotid sinus massage
• Hypersensitive carotid sinus syndrome
• Stimulation of carotid sinus leads to bradyasystole and then to
pre/syncope
• Cardioinhibitory: >3s of asystole with carotid stimulation
• Vasodepressor effects
VALVULAR DISEASE
• SA node is normal
• Normal P wave
• AV node conducts more slowly than normal
• Prolonged PR interval >0.2s
• PR interval is constant
• Rest of conduction is normal
• Normal QRS
FIRST DEGREE AVB
PR PR PR DROPPED BEAT
MOBITZ TYPE I
• Clinical implications:
• Often asymptomatic
• May have some symptoms eg lethargy, confusion
• If cardiac output is reduced, patient may experience angina, syncope or heart
failure due to bradycardia and resultant hypoperfusion state.
• Can occur in athletes with high vagal tone
• Elderly: aging prolongs cycle length
FURTHER IMPLICATIONS:
• Underlying IHD:
• Mobitz type I can be complication of inferior MI as:
• RCA supplies inferior and posterior walls and AV and SA nodes
• Associated with increased mortality
• Treatment:
• Removing reversible causes (ischemia, increased vagal tone,
medications
• Pacemaker if symptomatic during day
• No pacemaker is symptoms at night
• May progress to 3rd degree AVB
MOBITZ TYPE II
MOBITZ TYPE II AVB
• Clinical Implications:
• Dizziness
• Presyncope
• Syncope
• Ventricular tachycardia
• Ventricular fibrillation
• Confusion
• Can worsen angina and CHF
• Treatment:
• Pacemaker!