Atrioventricular Block

an interruption or delay of electrical conduction from the atria

to the ventricles due to conduction system abnormalities in the
AV node or the His-Purkinje system.
Definition
• Physiologic: the atrial rate is abnormally fast
• Pathologic: the atrial rate is normal
 Classificaction
first-, second-, and, third-degree AV block
 1 st Degree AV Block

History Symptoms
• High vagal tone • Generally asymptomatic
• Acute inferior myocardial infarction (MI) • Excessive delay causes dyspnoea, weakness,
• Use of antiarrhythmic medication(s) or dizziness

• Being a conditioned athlete

• Hypokalemia, hypomagnesemia
• Degeneration of the AV node
 Diagnostic Criteria
AV Block I

ECG 12 leads

sinus rhythm
regular
PR interval >0.20 s
 2 nd Degree AV Block

History Symptoms
• Inflammatory disease • Fatigue
• Infiltrative disease • Shortness of breath
• Hyperkalemia • Exercise intolerance
• Catheter ablation of the slow pathway • Dizziness
• Valve replacement surgery • Syncope
• Acute MI • Chest pain
Diagnostic Criteria for AV Blok II
One or more P wave is not followed by QRS complex (ratio 5:2, 4:3, 3:2, etc)

AV Blok II Mobitz type 1 AV Blok II Mobitz type 2

• Irregular heart rate • Bradycardia
• Progressive prolongation of the PR interval • PR interval remains the same (no prolongation)
• Narrow QRS complex • Wide QRS complex
 3 rd Degree
History Symptoms
• Degenerative disease • Fatigue
• Infiltrative disease • Shortness of breath
• Myocarditis • Exercise intolerance
• Neuromuscular disease • Light-headedness, dizziness
• Ischemia/infarction • Syncope
• Hypoxia • Chest pain
• Hyperkalemia • Neck palpitations
• Use of antiarrhythmic medication(s)
 Diagnostic Criteria for AV Blok III
ECG 12 leads: P waves dan QRS complexes are completely independent

Escape rhythm depends on the location of the block:

Junction
• idio-junctional rhythm
• narrow QRS complexes
• heart rate is relatively faster

Ventricle
• idio-ventricular rhythm
• wide QRS complexes
• heart rate is relatively slower
 Laboratory Examination

if elevated potassium level or drug toxicity is suspected if AV block is suspected due to ischemia/infarction in cases of systemic illness

Electrolyte levels (hyperkalemia) Troponin levels Infection (Lyme titres)

Drug levels (e.g. digitalis) Myxoedema (TSH levels)
Connective tissue disease (ANA)
 Electrocardiogram
• 12-Lead ECG recordings and/or rhythm/monitor strips
• 24-Hour and/or prolonged monitoring
• Implantable loop recorder

Additional Modalities
Electrophysiologic test à determine the location of the block and other arrhythmias
Echocardiography à assess ventricular function (especially if an implantable device is required)
Exercise test à assess if AV block worsens or improves with exercise
 Treatment
Medicines
• Anticholinergic à Atropine IV infusion
(0.5mg bolus, repeat every 3-5 minutes, max 3mg)
• Beta1 / beta2 adrenergic agonist à Epinephrine IV infusion
(2-20 mcg/kg per minute)
• Vasopressor, alpha/beta agonist à Dopamine IV infusion
(2-10 mcg per minute)

Pacemaker implantation (if medication is ineffective)

For AV Blok II with symptoms, AV Blok III with symptoms, or AV Blok III with HR<40 bpm

*If arrhythmia is left untreated, the heart may not be able to pump enough blood to the body
↓
damage the heart, the brain, or other organs.