BRADYARRHYTHMIAS & DEVICES

Dr. Syed Haseeb Raza

FCPS Cardiology, Clinical Cardiac Electrophysiologist
Author of ECG Book and Researcher
National Institute of Cardiovascular Diseases, Karachi, Pakistan.
 CASE 1
66yr ,Male, Shortness Of Breath And Dizziness On
Running

What will you do next ?

 EXERCISE STRESS TEST

Inability to adequately increase

heart rate

Failure to achieve 80% of the expected

maximum heart rate ( age adjusted)

Your patient is not able to achieve 80%

of the expected maximum heart rate

Will you implant a PPM ?

In patients with symptomatic chronotropic incompetence,
permanent pacing with rate-responsive programming is
reasonable to increase exertional heart
rates and improve symptoms. (Class II a)
 CASE 2
70yr ,Female, Dizzy spells while watching TV

What is the Rhythm ?

SA node exit block type II
 CASE 2
Same patient. Previous record shows ?

Will you implant a PPM ?

 YES

When there is direct evidence of symptom correlating with

sinus bradycardia or pauses, permanent cardiac pacing will lead
to clinical improvement. Such a temporal symptom-
bradycardia correlation is regarded as the gold standard of
diagnosis and confers the highest likelihood of response
therapy. ( Class I )
A)

WHAT IS THE RHYTHM ?

B)
“In sinus node dysfunction, there is no established minimum
heart rate or pause duration where permanent pacing is
recommended. Establishing temporal correlation between
symptoms and bradycardia is important when determining
whether permanent pacing is needed.”

2018 ACC/AHA/HRS Bradycardia and

Cardiac Conduction Delay
 CASE 3
51yr ,Male, usual checkup for diabetes mellitus

Will you implant PPM ?

NO
 CASE 4
47yr ,Male, Episodic Dizzy spells for last 1 week

What will be the next best step ?

 AMBULATORY ELECTROCARDIOGRAPHIC MONITORING

In patients with symptoms (e.g., lightheadedness, dizziness) of unclear

etiology who have first-degree atrioventricular block or second-degree Mobitz
type I atrioventricular block on ECG, ambulatory electrocardiographic
monitoring is reasonable to establish correlation between symptoms and
rhythm abnormalities ( Class II a)

In patients with exertional symptoms (e.g., chest pain, shortness of breath)

who have first-degree or second-degree Mobitz type I atrioventricular block
at rest, an exercise treadmill test is reasonable to determine whether they
may benefit from permanent pacing. ( Class II a )
 CASE 5
47yr ,Female, HTN, Headache and Anxiety, Atenolol 100mg OD

Is she a candidate of PPM right now

?
 NO

Rule out the reversible causes first e.g. drugs

 CASE 6
55yr ,Male, ICMP, Sinking of heart/Dizziness,
Ascard 75mg, Atorva 20 mg, Enalapril 5 mg BD, Carvedilol 12.5mg BD

Is he a candidate of PPM right now ?

 YES,

Essential drug therapy beta blocker

 CASE 7
66yr ,Male, Anxious about Missing in pulse for last 1 day

Will you implant PPM right now ?

 NO

Blocked APC’s
 CASE 8
66yr ,Male, lightheadedness / dizziness

What will you do now ?

 2:1 AV Block

Correlate the symptoms with block through Ambulatory ECG recording or

E.T.T ( class II a )

Although a narrow QRS complex suggests that the block is at the level of the
atrioventricular node, there are instances where it has been determined to
be infranodal during an EPS. Symptoms may be difficult to correlate but
ambulatory electrocardiographic monitoring or a treadmill exercise test may
be useful.

In patients with first-degree atrioventricular block or second-degree Mobitz

type I (Wenckebach) or 2:1 atrioventricular block which is believed to be at
the level of the atrioventricular node, with symptoms that do not temporally
correspond to the atrioventricular block, permanent pacing should not be
performed. ( Class III )
 CASE 9
61yr ,Male, presyncope

What will you do now ?

 A.Fib with pause

If the pauses are causing symptoms or if the pauses are attributable to

infranodal block, the recommendation is similar to patients who are in
normal sinus rhythm. In the asymptomatic patient, there is specific pause
duration that warrants permanent pacing. (Class I)
“In patients with

1.Acquired second-degree Mobitz type II atrioventricular block

2.High-grade Atrioventricular block
3.Third-degree atrioventricular block not caused by reversible or
physiologic causes

permanent pacing is recommended regardless of symptoms.

For all other types of atrioventricular block, in the absence of

conditions associated with progressive atrioventricular
conduction abnormalities, permanent pacing should generally be
considered only in the presence of symptoms that correlate with
atrioventricular block.”

2018 ACC/AHA/HRS Bradycardia and

Cardiac Conduction Delay
 CASE 10
49yr ,Male, episodes of dizziness for last 8 months

What will you advice the patient ?

 AMBULATORY ECG MONITORING

In symptomatic patients with conduction system disease, in whom

atrioventricular block is suspected, ambulatory electrocardiographic
monitoring is useful. ( Class I )

In patients with symptoms suggestive of intermittent bradycardia (e.g.,

lightheadedness, syncope), with conduction system disease identified by
ECG and no demonstrated atrioventricular block, an EPS is reasonable.
(Class II a )
 CASE 11
66yr ,Female, diagnosed as SND, no AV node dysfunction

What will you advice the patient ?

a) AAI
b) VVI
c) DDD
d) CRT-P
 CASE 11
66yr ,Female, diagnosed as SND, no AV node dysfunction

What will you advice the patient ?

a) AAI
b) VVI
c) DDD
d) CRT-P
 CASE 12
32yr ,male, paroxysmal A.Fib and long pauses

What will you advice the patient ?

a) AAI
b) VVI
c) DDD
d) DDD with mode switch to VVI
 CASE 12
32yr ,male, paroxysmal A.Fib and long pauses

What will you advice the patient ?

a) AAI
b) VVI
c) DDD
d) DDD with mode switch to VVI
 CASE 13
38yr ,male, permanent A.Fib and long pauses

What will you advice the patient ?

a) AAI
b) VVI
c) DDD
d) DDD with mode switch to VVI
 CASE 13
38yr ,male, permanent A.Fib and long pauses

What will you advice the patient ?

a) AAI
b) VVI
c) DDD
d) DDD with mode switch to VVI
 CASE 14
71yr ,male, diabetic, Carotid sinus hypersensitivity

What will you advice the patient ?

a) AAI
b) VVI
c) DDD
d) CRT-P
 CASE 14
71yr ,male, diabetic, Carotid sinus hypersensitivity

What will you advice the patient ?

a) AAI
b) VVI
c) DDD
d) CRT-P
 CASE 15
36yr ,Female, High grade AV Block, Normal Sinus node
function, LVEF= 30%

What will you advice the patient ?

a) AAI
b) VVI
c) DDD
d) CRT-P
 CASE 15
36yr ,Female, High grade AV Block, Normal Sinus node
function, LVEF= 30%

What will you advice the patient ?

a) AAI
b) VVI
c) DDD
d) CRT-P
 CASE 16
72yr ,male, LVEF= 30%, NYHA IV on GDMT

What will you advice the patient ?

a) AAI b) VVI c) DDD d) CRT-P
 CASE 16
72yr ,male, LVEF= 30%, NYHA IV on GDMT

What will you advice the patient ?

a) AAI b) VVI c) DDD d) CRT-P
 CASE 17
66yr ,Female, Complete AV Block (TPM dependent),
LVEF= 40%

What will you advice the patient ?

a) AAI
b) VVI
c) DDD
d) CRT-P
 CASE 17
66yr ,Female, Complete AV Block (TPM dependent),
LVEF= 40%

What will you advice the patient ?

a) AAI
b) VVI
c) DDD
d) CRT-P
 CASE 19
43 yr, Smoker, Chest pain for last 2 hrs, diagnosed as Acute
Anterolateral STEMI, Successful Primary PCI done without any
complications.

He remained asymptomatic. At 3rd day just before getting discharged

patient developed unstable VT which was DC cardioverted by on duty
doctor. Regarding this arrhythmia ,

What is the best next step ?

A) Amiodarone
B) EP study
C) ICD
D ) Rule out the reversible causes
 CASE 19
43 yr, Smoker, Chest pain for last 2 hrs, diagnosed as Acute
Anterolateral STEMI, Successful Primary PCI done without any
complications.

He remained asymptomatic. At 3rd day just before getting discharged

patient developed unstable VT which was DC cardioverted by on duty
doctor. Regarding this arrhythmia ,

What is the best next step ?

A) Amiodarone
B) EP study
C) ICD
D ) Rule out the reversible causes
 CASE 20

Same Patient . All Reversible causes ruled out

What is the best next step ?

A) Amiodarone
B) EP study
C) ICD
D ) Rule out the reversible causes again
 CASE 20

Same Patient . All Reversible causes ruled out

What is the best next step ?

A) Amiodarone
B) EP study
C) ICD
D ) Rule out the reversible causes again
C) ICD
 CASE 21
52 yr, Male smoker, Chest pain for last 2 hours, diagnosed as Acute
Anterolateral STEMI, Successful Primary PCI done without any
complications and discharged after 4 days.

On 8th day patient presented with cardiac syncope. On examination

His CNS system was unremarkable .

His ECHO shows LVEF = 40%

What is the best next step ?

A) oral Amiodarone
B) HUTT
C) EP study
D) ICD
E ) Re-do Cor Angiogram
 CASE 21
52 yr, Male smoker, Chest pain for last 2 hours, diagnosed as Acute
Anterolateral STEMI, Successful Primary PCI done without any
complications and discharged after 4 days.

On 8th day patient presented with cardiac syncope. On examination

His CNS system was unremarkable .

His ECHO shows LVEF = 40%

What is the best next step ?

A) oral Amiodarone
B) HUTT
C) EP study
D) ICD
E ) Re-do Cor Angiogram
.
 CASE 22
Same Patient. His EP study was done and showed no inducible VA.

What is the best next step ?

A) oral Amiodarone
B) HUTT
C) again EP study
D) ICD
E ) just monitoring
 CASE 22
Same Patient. His EP study was done and showed no inducible VA.

What is the best next step ?

A) oral Amiodarone
B) HUTT
C) again EP study
D) ICD
E ) just monitoring
.
 CASE 23
49 yr, Male smoker, Chest pain for last 2 hours, diagnosed as Acute
Anterolateral STEMI, Successful Primary PCI done without any
complications and discharged after 4 days.

On 8th day patient presented with syncope. On examination His CNS

system was unremakable .

His ECHO shows LVEF = 30%

What is the best next step ?

A) oral Amiodarone
B) HUTT
C) EP study
D) ICD
E ) Re-do Cor Angiogram
 CASE 23
49 yr, Male smoker, Chest pain for last 2 hours, diagnosed as Acute
Anterolateral STEMI, Successful Primary PCI done without any
complications and discharged after 4 days.

On 8th day patient presented with syncope. On examination His CNS

system was unremakable .

His ECHO shows LVEF = 30%

What is the best next step ?

A) oral Amiodarone
B) HUTT
C) EP study
D) ICD
E ) Re-do Cor Angiogram
.
 CASE 24
59 yr, Male smoker, Chest pain for last 2 hours, diagnosed as Acute
Anterolateral STEMI, Successful Primary PCI done without any
complications and discharged. His hospital stay uncomplicated.

At Follow up :
LVEF at 90 days post PCI = 40%
ECG showing “runs of NSVT”

What is the best next step for prevention of SCD?

A) ICD
B) EP
C) continue GDMT
D ) Start Amiodarone
 CASE 24
59 yr, Male smoker, Chest pain for last 2 hours, diagnosed as Acute
Anterolateral STEMI, Successful Primary PCI done without any
complications and discharged. His hospital stay uncomplicated.

At Follow up :
LVEF at 90 days post PCI = 40%
ECG showing “runs of NSVT”

What is the best next step for prevention of SCD?

A) ICD
B) EP
C) continue GDMT
D ) Start Amiodarone
 CASE 24
Same patient

No inducible VT on EP study

What is the best next step for prevention of SCD?

A) ICD
B) EP
C) continue GDMT
D ) Start Amiodarone
 CASE 24
Same patient

No inducible VT on EP study

What is the best next step for prevention of SCD?

A) ICD
B) EP
C) continue GDMT
D ) Start Amiodarone
.