Bradycardia Case File

https://medical-phd.blogspot.com/2021/04/bradycardia-case-file.html

Eugene C. Toy, Md, Michael d . Faulx, Md

Case 12
A 75-year-old man with a history of hypertension, hyperlipidemia, and coronary artery disease with
drug-eluting stent placement 5 years ago presents with a com plaint of lightheadedness and fatigue,
ongoing for the past 24 hours. He has not experienced any episodes of syncope, chest pain,
shortness of breath, or palpitations. He was able to ambulate to your office, and is fully conversant
with you; however, he does state that these activities were significantly more difficult to per form
than usual, and he had to stop multiple times to rest coming from the parking lot to your office. He
appears fatigued in general. He is afebrile with a blood pressure of 110/60 mmHg, heart rate of 30
bpm, and breathing rate of 14 times per minute. On examination, his lungs are clear, and he does
not have any lower extremity edema. His cardiac examination is significant for bradycardia without
murmurs, rubs, or gallops. Neck examination shows intermittent large jugular venous pulsations.
Peripheral pulses are strong. Laboratory evaluation shows normal blood count, renal function,
electrolytes, thyroid function tests, and no elevation in serum cardiac biomarkers. An ECG is
obtained in office and is shown in Figure 12-1.

c What is the most likely diagnosis?

c What else do you need to know about his medical history?
c What is the best next step in management?

Figure 12-1. An ECG for the main subject of this case.

Answer to Case 12:
Bradycardia

Summary: A 75-year-old man with little comorbid history presents with a 1-week history of fatigue
and lightheadedness, with no other significant symptoms. Examination is significant for severe
bradycardia. There is no laboratory evidence of renal impairment or acute or ongoing myocardial
ischemia or infarction. ECG shows abnormal conduction through the AV node, with dissociation of
the atrial (P waves) and ventricular (QRS) activation.

 Most likely diagnosis: Complete heart block (third-degree AV block).

 What else is needed to know about his medical history? Medications taken by patient or
recent changes in his regimen.
 Next step in management: Ventricular pacing.

ANALYSIS

Objectives

1. Know how to interpret an electrocardiogram (ECG) and identify the different types of AV
block.
2. Recognize key factors that need to be identified and evaluated as part of management of
patients with conduction abnormalities.
3. Understand key physical exam findings in patients with complete heart block.
4. Understand different maneuvers that can be employed in the evaluation of patients with
second-degree AV block to differentiate Mobitz 1 from Mobitz 2 block.

Considerations
This 75-year-old man presents with severe bradycardia for 24 hours, with associated symptoms
(lightheadedness and fatigue). The first, and most important, step in diagnosis of a patient
presenting with these symptoms and exam finding of bradycardia is electrocardiogram (ECG). The
ECG will provide the diagnosis of what the conduction abnormality is (sinus bradycardia vs.
second-degree AV block type 1 or type 2 vs. complete heart block), where the ventricular
activation is coming from if complete heart block is present (narrow complex suggesting junctional
escape, wide complex suggesting ventricular escape), as well as providing other pertinent
information such as the presence of active myocardial ischemia or infarction, or interventricular
conduction abnormalities (right or left bundle branch block). This ECG shows complete heart
block, identified by dissociation of the atrial and ventricular activation, with more P waves than
QRS complexes. Further, the ventricular rate is very slow, and in the presence of symptoms, is not
ultimately sustainable. The next immediate step is to stabilize the patient with temporary
ventricular pacing. While this patient ultimately may require permanent pacemaker implantation,
this process would not occur likely for hours at a minimum, and therefore more immediate
intervention is warranted.

Transcutaneous pacing with external pads is an option, but not an ideal one as they are often
uncomfortable for the patient and are typically unreliable with either complete inability to pace, or
intermittent loss of capture. Transvenous temporary pacing provides more reliability, better pacing
options, and aside from initial venous access, is more comfortable for the patient while further
workup and planning is done; this can be performed by a trained cardiologist or intensivist.

Finally, after stabilization, baseline workup can commence. Careful review of the patient’s
medication list, as well as recent changes, is needed as many medications (beta-blockers, calcium
channel blockers, digoxin, antiarrhythmics) may cause AV block that can be resolved with
decreasing dose, cessation, or pharmacologic reversal of the agent. Lab evaluation with complete
blood count (CBC), comprehensive metabolic panel (CMP; a standardized group of 14 blood tests),
and thyroid-stimulating hormone (TSH) blood tests are important to rule out end-organ
dysfunction, which may result from hypoperfusion due to bradycardia, as well as ensure that
electrolyte or thyroid dysfunction are not culprits in the presenting situation. Cardiac evaluation
should include exclusion of myocardial infarction with serial CK, CK-MB, and troponin T or I, as
active ischemia or infarct may cause AV conduction abnormalities; and an echocardiogram should
be performed to evaluate for baseline LV function, wall motion, and valvular abnormalities. In
patients with known severe coronary artery disease, or suspicion of disease due to concomitant
symptoms (chest pain, shortness of breath, heart failure symptoms), evaluation for ischemia or
severe coronary disease may be necessary with noninvasive stress testing or cardiac catheterization.

Approach To:
Bradycardia

DEFINITIONS
BRADYCARDIA: Ventricular rate <60 bpm.

COMPLETE HEART BLOCK: Dissociation of atrial and ventricular activation.

SECOND-DEGREE HEART BLOCK, MOBITZ TYPE 1: PR interval that progressively

prolongs before a nonconducted P wave occurs, resulting in a “dropped” QRS for a single beat.

SECOND-DEGREE HEART BLOCK, MOBITZ TYPE 2: PR interval is consistent beat to

beat, and a QRS is consistently dropped, typically at a regular interval (3:2, 4:3, etc).