Heart Block

The heart's "natural" pacemaker is called the sinoatrial (SA) node or sinus node. It's a small mass of specialized cells in the heart's right atrium. It produces electrical impulses that makes the heart beat. For the heart to beat properly, the signal must travel from the SA node down a specific path to reach the ventricles. As the signal goes from the atria to the ventricles, it passes through specialized conducting tissue called the atrioventricular (AV) node. On an electrocardiogram (ECG), a portion of the graph called the P wave shows the impulse passing through the atria. Another portion of the graph, the QRS wave, shows the impulse passing through the ventricles. As long as the impulse is transmitted normally, the heart pumps and beats at a regular pace.
CASE SCENARIO MR.James Yap is a 49 yr old patient,who was scheduled for an anual medical check up.Laboratory examinations like blood chemistry, CBC,x-ray and an ECG was taken.His cardiologist incidentally noted on ECG,first degree heart block, without any particular associated symptoms noted on mr.x.It was documented that mr.x is taking atenolol a beta blocker as his maintenance for his high blood pressure.

Anatomy and physiology

The heart's electrical activity normally starts in the sinoatrial node (the heart's natural pacemaker), which is situated on the upper right atrium. From there the impulse travels to the left atrium and the atrioventricular node. From the AV node the electrical impulse travels down the Bundle of His and divides into the right and left bundle branches. The right bundle branch contains one fascicle. The left bundle branch subdivides into two fascicles: the left anterior fascicle and the left posterior fascicle. Ultimately, the fascicles divide into millions of Purkinje fibers which in turn interdigitize with individual cardiac myocytes, allowing for rapid, coordinated, and synchronous depolarization of the ventricles

Pathophysiology

With first-degree AV block, every atrial impulse is transmitted to the ventricles, resulting in a regular ventricular rate. This type of AV block can arise from delays in the conduction system in the AV node itself, the His-Purkinje system, or a combination of both. Overall, dysfunction at the AV node is much more common than dysfunction at the His-Purkinje system. If the QRS complex is of normal width and morphology on the ECG, then the conduction delay is almost always at the level of the AV node. If, however, the QRS demonstrates a bundle-branch morphology, then the level of the conduction delay is often localized to the His-Purkinje system.
Causes

The following are the most common causes

o o o o

Intrinsic AV nodal disease Enhanced vagal tone Acute MI, particularly acute inferior wall MI Myocarditis

Electrolyte disturbances Drugs (especially those drugs that increase the refractory time of the AV node, thereby slowing conduction) Drugs that most commonly cause first-degree AV block include the following:
o o o o o o o

o o

Class Ia antiarrhythmics (eg, quinidine, procainamide, disopyramide) Class Ic antiarrhythmics (eg, flecainide, encainide, propafenone) Class II antiarrhythmics (beta-blockers) Class III antiarrhythmics (eg, amiodarone, sotalol, dofetilide, ibutilide) Class IV antiarrhythmics (calcium channel blockers) Digoxin or other cardiac glycosides Magnesium

Symptoms of Heart Block

Symptoms of heart block may include the following. Sometimes, however, there are no symptoms at all.

Syncope (fainting) Dizziness Lightheadedness Chest pain Shortness of breath

Risk Factors

History of cardiac disease (for example, myocardial infarction, congestive heart failure, valvular failure). Some medications or exposure to toxic substances can cause heart block or other types of bradycardia. Other prior illnesses

Diagnosis
In normal individuals, the AV node slows the conduction of electrical impulse through the heart. This is manifest on a surface ECG as the PR interval. The normal PR interval is from 120 ms to 200 ms in length. This is measured from the initial deflection of the P wave to the beginning of the QRS complex. In first degree heart block, the diseased AV node conducts the electrical activity slower. This is seen as a PR interval greater than 200 ms in length on the surface ECG. It is usually an incidental finding on a routine ECG.

First degree heart block does not require any particular investigations except for electrolyte and drug screens especially if an overdose is suspected.

TREATMENT
The management includes identifying and correcting electrolyte imbalances and withholding any offending medications. This condition does not require admission unless there is an associated myocardial infarction. Even though it usually does not progress to higher forms of heart block, it may require outpatient follow up and monitoring of the ECG especially if there is a comorbid bundle branch block. If there is a need for treatment of an unrelated condition care should be taken not to introduce any medication that may slow AV conduction. If this is not fular monitoring of the ECG is indicator or necessarily even prolongation of the PR interval.
HEART BLOCK SECOND DEGREE Second degree heart block, or second degree AV block, refers to a cardiac conduction system disorder in which some P waves fail to conduct to the ventricle and generate a QRS complex. It is divided into 2 types: Mobitz I and Mobitz II. Mobitz I second degree AV block, or Wenckebach block, is characterized by progressive prolongation of the PR interval causing progressive RR interval shortening until a P wave fails to conduct to the ventricle. Mobitz II second degree AV block is characterized by sudden unexpected blocked P waves without variation or necessarily even prolongation of the PR interval. Pathophysiology: Mobitz I Wenckebach block is caused by conduction delay in the AV node in 72% of patients and by His-Purkinje system conduction delay in the other 28%. The presence of a narrow QRS complex makes the site of delay even more likely to be at the AV node. Wenckebach block and a wide complex QRS may be due to AV nodal or infranodal conduction delay. Mobitz II block is due to infranodal His-Purkinje system conduction delay, electrophysiological studies have proved. It is generally associated with a wide QRS complex except in some of the patients with delay localized within the His bundle.

Causes: Mobitz I Wenckebach block can be caused by acute inferior myocardial infarction, states of vagal stimulation or enhanced vagal tone, or toxicity relating to digitalis, beta-blockers, or calcium channel blockers. Mobitz II block is most commonly caused by acute myocardial

infarction (anterior or inferior).

DIAGNOSTIC PROCEDURE For the evaluation of patients with second degree heart block, serum electrolytes may be checked and a digoxin level is indicated for those patients on digoxin. Cardiac enzymes are indicated for any patient with suspected myocardial ischemia, paticulary those with type II block. Imaging Studies: Routine imaging studies are not required, although a chest radiograph may be appropriate for those with associated signs and symptoms of myocardial ischemia. Other Tests: Follow-up ECG's and cardiac monitoring are appropriate for patients with second degree heart block. TREATMENT Second degree heart block requires no specific prehospital therapy, unless the patient is symptomatic from a resulting bradycardia. In this case, standard ACLS guidelines should be followed, including the use of atropine and transcutaneous pacing. Mobitz I Wenckebach block requires no specific ED therapy. Those patients with associated myocardial ischemia should be treated with appropriate anti-ischemic medications. Those on AV nodal agents should have them withheld. Those with symptomatic bradycardia should be treated with atropine and transcutaneous pacing, per standard ACLS guidelines. Caution should be used in administering atropine to a patient with suspected acute myocardial infarction because atropine has been reported to precipitate VT/VF in this situation. Mobitz II block requires more aggressive ED therapy. Certainly, AV nodal agents should be withheld and anti-ischemic therapy delivered where appropriate. In addition, given the propensity for progression to complete heart block, these patients should have transcutaneous pacing patches applied and tested, even when asymptomatic. Those with symptoms and those in whom transcutaneous pacing is tested unsuccessfully should have urgent cardiac consultation for the placement of a temporary transvenpous pacing wire.

Powerpoint

HEART BLOCK(atrioventricular block) -conduction defect within the AV junction that impairs conduction of atrial impulses to ventricular pathways .

3 TYPES 1)first degree 2)second degree 3)third degree

ANATOMY AND PHYSIOLOGY

Pathophysiology

With first-degree AV block, every atrial impulse is transmitted to the ventricles, resulting in a regular ventricular rate. This type of AV block can arise from delays in the conduction system in the AV node itself, the His-Purkinje system, or a combination of both. Overall, dysfunction at the AV node is much more common than dysfunction at the His-Purkinje system. If the QRS complex is of normal width and morphology on the ECG, then the conduction delay is almost always at the level of the AV node. If, however, the QRS demonstrates a bundle-branch morphology, then the level of the conduction delay is often localized to the His-Purkinje system.

DISEASE PRESENTATION A.first degree- atrial impulses are conducted through the AV node into ventricles at a rate alower than normal B.second degree- some signals from the atria dont reach the ventricle -impulses are not regularly conducted through av node junction 1.type 1 2nd degree heart block(mobitz type I) -electrical impulses are delayed more and more with each heartbeat until a beat is skipped 2.type II 2nd degree heart block -more serious than type I -elctrical impulses cant reach the ventricles
C.third degree(complete heart block)-no atria impulses is conducted through av node into ventricles CHARACTERISTICS A.RATE First degree-60-100bpm Second degree-rate is slowed

Third degree-40-60bpm B.Pwave-normal in each type of block C.PR intervals First degree-prolonged,greater than 0.20sec Second degree-PR interval becomes longer Third degree-PR interval is constant D.QRS complex First degree-normal Second degree-normal Third degree-widened

CAUSES OF HEART BLOCK Medication Myocardial infarction Myocarditis Increased vagal tone Electrolyte disturbances

ASSESSMENT FINDINGS First degree-asymptomatic Second degree-vertigo, lightheadedness,irregular pulse,chest pain,SOB DIAGNOSTIC PROCEDURE 1.ECG 2.serum electrolyte and digoxin level 3.cardiac enzyme(suspect MI)

MEDICAL MANAGEMENT

1.Atropine(anticholinergic)IV bolus 2.transcutaneous pacing 3.Pacemaker