Advertisement

Evidenced-Based Approach to Bradyarrhythmias

Chapter

Abstract

Bradycardia can be caused by a wide variety of factors that affect the sinoatrial or the atrioventricular nodes. The sinus node is the main pacemaker of the heart and is extremely sensitive to autonomic influences as it is richly innervated by sympathetic and parasympathetic nerve inputs. Sinus node dysfunction is a result of various intrinsic or extrinsic causes, most commonly aging and medications. The clinical presentation can vary widely with electrocardiographic (ECG) manifestations including sinus bradycardia, sinus arrest, sinoatrial exit block, hypersensitive carotid sinus syndrome, chronotropic incompetence, and tachycardia-bradycardia syndrome. The key to the diagnosis is correlating symptoms to ECG findings. The only effective management is by pacing. The atrioventricular (AV) conduction axis has complex anatomical and physiological characteristics and the AV node is also strongly influenced by autonomic inputs. There are multiple causes of AV block divided into three ECG classifications – first-, second-, and third-degree AV block – based on the P wave to QRS complex relationship. Additional forms include 2:1, high-grade, and paroxysmal AV block which do not fit within those ECG classifications. Definitive therapy is pacemaker implantation which is indicated for treatment of symptoms with any form of AV block or an infranodal site of conduction block regardless of symptoms.

Keywords

Bradycardia Sinus node dysfunction Sinus bradycardia Sinus arrest Sinoatrial exit block Chronotropic incompetence Carotid sinus hypersensitivity Tachycardia-bradycardia syndrome Sick sinus syndrome Type 1 second-degree block Type 2 second-degree block Mobitz I Mobitz II Wenckebach 2:1 AV block High-grade AV block Complete AV block Infranodal AV block Pacemaker implantation 

References

  1. 1.
    Spodick DH. Normal sinus heart rate: sinus tachycardia and sinus bradycardia redefined. Am Heart J. 1992;124:1119–21.PubMedCrossRefGoogle Scholar
  2. 2.
    Rubart M, Zipes DP. Genesis of cardiac arrhythmias: electrophysiological considerations. In: Zipes DP, Libby P, Bonow R, Braunwald E, editors. Braunwald’s heart disease: a textbook of cardiovascular medicine. 7th ed. Philadelphia: WB Saunders; 2004. p. 653–88.Google Scholar
  3. 3.
    Kawashima T. The morphological significance of the human sinuatrial nodal branch (artery). Heart Vessels. 2003;18(4):213.PubMedCrossRefGoogle Scholar
  4. 4.
    Jalife J. Mutual entrainment and electrical coupling as mechanisms for synchronous firing of rabbit sino-atrial pace-maker cells. J Physiol. 1984;356:221–43.PubMedGoogle Scholar
  5. 5.
    Schwartz PJ, Zipes DP. Autonomic modulation of cardiac arrhythmias. In: Zipes DP, Jalife J, editors. Cardiac electrophysiology: from cell to bedside. 3rd ed. Philadelphia: WB Saunders; 1999. p. 300–14.Google Scholar
  6. 6.
    Lee RJ, Kalmasn JM, Fitzpatrick AP, et al. Radiofrequency catheter modification of the sinus node for “inappropriate” sinus tachycardia. Circulation. 1995;92:2919–28.PubMedCrossRefGoogle Scholar
  7. 7.
    Boyett MR, Honjo H, Kodama I. The sinoatrial node, a heterogeneous pacemaker structure. Cardiovasc Res. 2000;47:658.PubMedCrossRefGoogle Scholar
  8. 8.
    Lee RJ, Shinbane JS. Advances in supraventricular tachycardia. Cardiol Clin. 1997;15:599–605.PubMedCrossRefGoogle Scholar
  9. 9.
    Ferrer I. The sick sinus syndrome in atrial disease. JAMA. 1968;206:645–52.PubMedCrossRefGoogle Scholar
  10. 10.
    Dobrzynski H, Boyett MR, Anderson RH. New insights into pacemaker activity: promoting understanding of sick sinus syndrome. Circulation. 2007;115:1921.PubMedCrossRefGoogle Scholar
  11. 11.
    Rosenqvist M, Obel IW. Atrial pacing and the risk of AV block: is there a time for change in attitude? Pacing Clin Electrophysiol. 1989;12:97–101.PubMedGoogle Scholar
  12. 12.
    Mennozi C, Brignole M, Alboni P, et al. The natural course of untreated sick sinus syndrome and identification of variables predictive of unfavorable outcome. Am J Cardiol. 1998;82:1205–9.CrossRefGoogle Scholar
  13. 13.
    Anderson HR, Thuesen L, Bagger JP, et al. Prospective randomized trial of atrial versus ventricular pacing in sick sinus syndrome. Lancet. 1994;344:1523–8.CrossRefGoogle Scholar
  14. 14.
    Santini M, Alexidou G, Ansalone G, et al. Relation of prognosis in sick sinus syndrome to age, conduction defects and modes of permanent cardiac pacing. Am J Cardiol. 1990;65:729–35.PubMedCrossRefGoogle Scholar
  15. 15.
    Simonsen E, Nielsen JS, Nielsen BL. Sinus node dysfunction in 128 patients. A retrospective study with followup. Acta Med Scand. 1980;208:343–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Sweeney MO. Sinus node dysfunction. In: Zipes D, Jalife J, editors. Cardiac electrophysiology: from cell to bedside. Philadelphia: WB Saunders; 2004. p. 879–83.CrossRefGoogle Scholar
  17. 17.
    Alt E, Volker R, Witzfeld A, Ulm K. Survival and follow up after pacemaker implantation: a comparison of patients with sick sinus syndrome, complete heart block and atrial fibrillation. Pacing Clin Electrophysiol. 1985;8:849–55.PubMedCrossRefGoogle Scholar
  18. 18.
    Simon AB, Janz N. Symptomatic bradyarrhythmias in the adult: natural history following ventricular pacemaker implantation. Pacing Clin Electrophysiol. 1982;5:372–83.PubMedCrossRefGoogle Scholar
  19. 19.
    Elvan A, Wylie K, Zipes DP. Pacing-induced chronic atrial fibrillation impairs sinus node function in dogs: electrophysiological remodeling. Circulation. 1996;94:2953–60.PubMedCrossRefGoogle Scholar
  20. 20.
    Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation. 2008;117:e350–408 [Erratum, Circulation 2009;120(5):e34–5].PubMedCrossRefGoogle Scholar
  21. 21.
    Andersen HR, Thuesen L, Bagger JP, et al. Prospective randomized trial of atrial versus ventricular pacing in sick sinus syndrome. Lancet. 1994;344:1523–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Andersen HR, Nielsen JC, Rhomsen PEB, et al. Long term follow-up of patients from a randomized trial of atrial versus ventricular pacing for sick sinus syndrome. Lancet. 1997;350:1210–6.PubMedCrossRefGoogle Scholar
  23. 23.
    Ac S, Krahn AD, Yee R, et al. Progression to chronic atrial fibrillation after pacing: the Canadian Trial of Physiological Pacing. CTOPP Investigators. J Am Coll Cardiol. 2001;38:167–72.CrossRefGoogle Scholar
  24. 24.
    Lamas GA, Lee KL, Sweeney MO, et al. Ventricular pacing or dual chamber pacing for sinus node dysfunction. N Engl J Med. 2002;346:1854–62.PubMedCrossRefGoogle Scholar
  25. 25.
    Rubart M, Zipes DP. Genesis of cardiac arrhythmias: electrophysiological considerations. In: Zipes DP, Libby P, Bonow R, Braunwald E, editors. Braunwalds heart disease: a textbook of cardiovascular medicine. 7th ed. Philadelphia: WB Saunders; 2004. p. 653–88.Google Scholar
  26. 26.
    Lev M. Anatomic basis for atrioventricular block. Am J Med. 1964;37:742.PubMedCrossRefGoogle Scholar
  27. 27.
    Lev M. The pathology of complete atrioventricular block. Prog Cardiovasc Dis. 1964;6:317.PubMedCrossRefGoogle Scholar
  28. 28.
    Zoob M, Smith KS. The aetiology of complete heart-block. Br Med J. 1963;2(5366):1149.PubMedCrossRefGoogle Scholar
  29. 29.
    Levine SA, Miller H, Penton GB. Some clinical features of complete heart block. Circulation. 1956;13(6):801.PubMedCrossRefGoogle Scholar
  30. 30.
    Hejtmancik MR, Herrmann GR, Shields AH, Wright JC. A clinical study of complete heart block. Am Heart J. 1956;52(3):369.PubMedCrossRefGoogle Scholar
  31. 31.
    Rowe JC, White PD. Complete heart block: a follow-up study. Ann Intern Med. 1958;49(2):260.PubMedCrossRefGoogle Scholar
  32. 32.
    Schwartzman D. Atrioventricular block and atrioventricular dissociation. In: Zipes DP, Jalife J, editors. Cardiac electrophysiology: from cell to bedside. 4th ed. Philadelphia: WB Saunders; 2004. p. 485–9.CrossRefGoogle Scholar
  33. 33.
    Wellens HJJ. Atrioventricular nodal and subnodal ventricular disturbances. In: Willerson J, Cohn J, Wellens Jr H, Holmes D, editors. Cardiovascular medicine. New York: Springer; 2007. p. 1991–8.CrossRefGoogle Scholar
  34. 34.
    Olgin JE, Zipes DP. Specific arrhythmias: diagnosis and treatment. In: Zipes DP, Libby P, Bonow R, Braunwald E, editors. Braunwald’s heart disease: a textbook of cardiovascular medicine. 7th ed. Philadelphia: WB Saunders; 2004. p. 803–64.Google Scholar
  35. 35.
    Zeltser D, Justo D, Halkin A, Rosso R, Ish-Shalom M, Hochenberg M, Viskin S. Drug-induced atrioventricular block: prognosis after discontinuation of the culprit drug. J Am Coll Cardiol. 2004;44(1):105.PubMedCrossRefGoogle Scholar
  36. 36.
    Erdogan HB, Kayalar N, Ardal H, Omeroglu SN, Kirali K, Guler M, Akinci E, Yakut C. Risk factors for requirement of permanent pacemaker implantation after aortic valve replacement. J Card Surg. 2006;21:211–5.PubMedCrossRefGoogle Scholar
  37. 37.
    Limongelli G, Ducceschi V, D’Andrea A, Renzulli A, Sarubbi B, De Feo M, Cerasuolo F, Calabro R, Cotrufo M. Risk factors for pacemaker implantation following aortic valve replacement: a single centre experience. Heart. 2003;89:901–4.PubMedCrossRefGoogle Scholar
  38. 38.
    Khawaja MZ, Rajani R, Cook A, Khavandi A, Moynagh A, Chowdhary S, Spence MS, Brown S, Khan SQ, Walker N, Trivedi U, Hutchinson N, De Belder AJ, Moat N, Blackman DJ, Levy RD, Manoharan G, Roberts D, Khogali SS, Crean P, Brecker SJ, Baumbach A, Mullen M, Laborde JC, Hildick-Smith D. Permanent pacemaker insertion after CoreValve transcatheter aortic valve implantation: incidence and contributing factors (the UK CoreValve collaborative). Circulation. 2011;123(9):951.PubMedCrossRefGoogle Scholar
  39. 39.
    Roten L, Wenaweser P, Delacrétaz E, Hellige G, Stortecky S, Tanner H, Pilgrim T, Kadner A, Eberle B, Zwahlen M, Carrel T, Meier B, Windecker S. Incidence and predictors of atrioventricular conduction impairment after transcatheter aortic valve implantation. Am J Cardiol. 2010;106(10):1473.PubMedCrossRefGoogle Scholar
  40. 40.
    Chang SM, Nagueh SF, Spencer 3rd WH, Lakkis NM. Complete heart block: determinants and clinical impact in patients with hypertrophic obstructive cardiomyopathy undergoing nonsurgical septal reduction therapy. J Am Coll Cardiol. 2003;42(2):296.PubMedCrossRefGoogle Scholar
  41. 41.
    Nagueh SF, Ommen SR, Lakkis NM, Killip D, Zoghbi WA, Schaff HV, Danielson GK, Quiñones MA, Tajik AJ, Spencer WH. Comparison of ethanol septal reduction therapy with surgical myectomy for the treatment of hypertrophic obstructive cardiomyopathy. J Am Coll Cardiol. 2001;38(6):1701.PubMedCrossRefGoogle Scholar
  42. 42.
    Scheinman MM, Huang S. The 1998 NASPE prospective catheter ablation registry. Pacing Clin Electrophysiol. 2000;23(6):1020.PubMedCrossRefGoogle Scholar
  43. 43.
    Fish AE, Pride YB, Pinto DS. Lyme carditis. Infect Dis Clin North Am. 2008;22(2):275.PubMedCrossRefGoogle Scholar
  44. 44.
    Josephson ME. Atrioventricular conduction. In: Clinical cardiac electrophysiology: techniques and interpretations. 4th ed. Philadelphia: Lea & Febiger; 1993.Google Scholar
  45. 45.
    Peuch P, Groileau R, Guimond C. Incidence of different types of A-V block and their localization by His bundle recordings. In: Wellens HJJ, Lie KI, Janse MJ, editors. The conduction system of the heart. Leiden: Stenfert; 1976. p. 467.Google Scholar
  46. 46.
    Scheinman MM, Peters RW, Suavé MJ, Desai J, Abbott JA, Cogan J, Wohl B, Williams K. Value of the H-Q interval in patients with bundle branch block and the role of prophylactic permanent pacing. Am J Cardiol. 1982;50(6):1316–22.PubMedCrossRefGoogle Scholar
  47. 47.
    Wenckebach KF. Zur analyse der unregelmässigen pulses. Ztschr klin Med. 1899;36:181.Google Scholar
  48. 48.
    Meytes I, Kaplinsky E, Yahini JH, Hanne-Paparo N, Neufeld HN. Wenckebach A-V block: a frequent feature following heavy physical training. Am Heart J. 1975;90(4):426.PubMedCrossRefGoogle Scholar
  49. 49.
    Zeppilli P, Fenici R, Sassara M, Pirrami MM, Caselli G. Wenckebach second-degree A-V block in top-ranking athletes: an old problem revisited. Am Heart J. 1980;100(3):281.PubMedCrossRefGoogle Scholar
  50. 50.
    Mobitz W. Über die unvollständige Störung der Erregungsüberleitung zwischen Vorhof und Kammer des menschlichen Herzens. Z Gesamte Exp Med. 1924;41:180.CrossRefGoogle Scholar
  51. 51.
    Strasberg B, Amat-Y-Leon F, Dhingra RC, Palileo E, Swiryn S, Bauernfeind R, Wyndham C, Rosen KM. Natural history of chronic second-degree atrioventricular nodal block. Circulation. 1981;63(5):1043.PubMedCrossRefGoogle Scholar
  52. 52.
    Barold SS. Atrioventricular block revisited. Compr Ther. 2002;28:74–8.PubMedCrossRefGoogle Scholar
  53. 53.
    Mymin D, Mathewson FA, Tate RB, Manfreda J. The natural history of primary first-degree atrioventricular heart block. N Engl J Med. 1986;315:1183–7.PubMedCrossRefGoogle Scholar
  54. 54.
    Dhingra RC, Denes P, Wu D, Chuquimia R, Rosen KM. The significance of second degree atrioventricular block and bundle branch block. Observations regarding site and type of block. Circulation. 1974;49:638–46.PubMedCrossRefGoogle Scholar
  55. 55.
    Barold SS. Indications for permanent cardiac pacing in first-degree AV block: class I, II, or III? Pacing Clin Electrophysiol. 1996;19:747–51.PubMedCrossRefGoogle Scholar
  56. 56.
    Recommendations for pacemaker prescription for symptomatic bradycardia. Report of a working party of the British Pacing and Electrophysiology Group. Br Heart J. 1991;66:185–91.Google Scholar
  57. 57.
    Connelly DT, Steinhaus DM. Mobitz type I atrioventricular block: an indication for permanent pacing? Pacing Clin Electrophysiol. 1996;19:261–4.PubMedCrossRefGoogle Scholar
  58. 58.
    Shaw DB, Kekwick CA, Veale D, Gowers J, Whistance T. Survival in second degree atrioventricular block. Br Heart J. 1985;53:587–93.PubMedCrossRefGoogle Scholar
  59. 59.
    Donoso E, Adler LN, Friedberg CK. Unusual forms of second-degree atrioventricular block, including mobitz type-II block, associated with the Morgagni-Adams-Stokes Syndrome. Am Heart J. 1964;67:150–7.PubMedCrossRefGoogle Scholar
  60. 60.
    Chokshi SK, Sarmiento J, Nazari J, Mattioni T, Zheutlin T, Kehoe R. Exercise-provoked distal atrioventricular block. Am J Cardiol. 1990;66:114–6.PubMedCrossRefGoogle Scholar
  61. 61.
    Hindman MC, Wagner GS, JaRo M, et al. The clinical significance of bundle branch block complicating acute myocardial infarction. 2. Indications for temporary and permanent pacemaker insertion. Circulation. 1978;58:689–99.PubMedCrossRefGoogle Scholar
  62. 62.
    Col JJ, Weinberg SL. The incidence and mortality of intraventricular conduction defects in acute myocardial infarction. Am J Cardiol. 1972;29:344–50.PubMedCrossRefGoogle Scholar
  63. 63.
    Ginks WR, Sutton R, Oh W, Leatham A. Long-term prognosis after acute anterior infarction with atrioventricular block. Br Heart J. 1977;39:186–9.PubMedCrossRefGoogle Scholar
  64. 64.
    Petrina M, Goodman SG, Eagle KA. The 12–lead electrocardiogram as a predictive tool of mortality after acute myocardial infarction: current status in an era of revascularization and reperfusion. Am Heart J. 2006;152:11–8.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2014

Authors and Affiliations

  1. 1.Section of Cardiac Electrophysiology, Division of CardiologySUNY/Stony Brook University Medical CenterStony BrookUSA

Personalised recommendations