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AV Heart Blocks

Heart Warden Holding a Block
tantheman
10 KEY FACTS
FIRST DEGREE
First Degree: PR> 200 Milliseconds
Purse with Greater than 200 Dollar Bills

In a first degree heart block, the PR interval is longer than 200msec, but the EKG is otherwise normal. In first degree AV block, all atrial impulses are conducted to the ventricle but are delayed. Patients with first degree AV block my be bradycardic but are often otherwise asymptomatic. Evidence of first degree AV block may be seen in healthy individuals who have a low resting heart rate, such as conditioned athletes. However it may also be a result of underlying cardiac pathology. Potentially pathologic etiologies of first degree (as well as second and third degree) heart blocks include ischemia involving the conduction system, cardiomyopathy (ie sarcoidosis), myocarditis (Lyme disease), hyperkalemia, and excess vagal stimulation. Iatrogenic causes include catheter ablation, valvular implantation, and medications such as AV-nodal blockers

No Treatment Needed
No Sign over Doctor

No treatment is needed for first degree heart blocks, as they are frequently asymptomatic. Patients found to have first degree heart block should be questioned about their medication regimen and risk factors relating to cardiac disease, as there is an overlap of cardiac conduction disturbances and other cardiac diseases including infiltrative cardiomyopathies, cardiomyopathies associated with muscular dystrophy, and other dilated cardiomyopathies. Patients with such diseases and risk factors may progress to more severe degrees of AV block, however a first degree AV block on its own does not warrant any intervention.

SECOND DEGREE
Mobitz I (Wenkebach): Progressive Lengthening of PR Intervals Leading to Dropped Beat
Winking-Bach and Progressively Longer PR-Purses, one Dropped Purse

Second degree heart blocks are characterized by intermittent atrial conduction to the ventricle. In other words, not all atrial impulses are conducted to the ventricle. Second degree blocks are further characterized into Mobitz I and Mobitz II, which are differentiated by their different patterns of intermittent conduction on EKG. Mobitz I is characterized by progressive lengthening of the PR interval until a QRS is dropped.

Exercise Improves, Vagal Maneuvers Worsen
Happy Face on a Treadmill, Sad Face on Vegas Sign

Symptoms of Mobitz I characteristically improve with exercise and worsen with vagal maneuvers. This is because vagal stimulation causes delay at the AV node via M2 muscarinic receptors, therefore worsening AV block. Conversely, sympathetic stimulation has the opposite effect.

Mobitz II: Dropped Beats With No Preceding PR Prolongation
Mobile Phone with Tutu Being Dropped with No Purse

In Mobitz II, beats are randomly dropped and there is no progressive PR prolongation as in Mobitz I

Atropine
@-trooper

Patients with Mobitz II require pacing either in the form of atropine if they are unstable, or transcutaneous pacing if they are stable. Atropine acts as a muscarinic antagonist at the M2 cholinergic receptors of the AV node. As activation of these receptors typically causes slowing of heart rate, blocking these receptors will increase heart rate.

Electrical pacing
Pacemaker

Stable patients with Mobitz II second degree AV block can be treated with electrical pacing, which may be done by a transcutaneous or transvenous approach. Electrical pacing works by generating an electrical signal that is able to bypass the pathological part of the conduction system that is causing the block. It is especially useful when atropine fails to correct a patient's bradycardia, which may occur if the pathological part of the conduction system is past the AV node, since atropine acts principally at the AV node.

THIRD DEGREE
Third Degree (complete): P Waves and QRS Beat Independently
QRS and P on Opposite Sides of the Panel

In a complete heart block, both P and QRS waves are present, but they bear no relation to each other

Treated With Pacing
Pacemaker

Patients with a third degree heartblock require pacing. This can be in the form of atropine if they are unstable, or transcutaneous pacing if they are unstable

Lyme Disease Can Cause 3rd Degree Block
Lime in the Third Panel

3rd degree heart block can be a result of Lyme disease. Because biopsies of the heart are rarely performed in cases of Lyme myocarditis and because Lyme myocarditis is rarely fatal, a relatively limited amount is known about the related pathophysiology. However based on animal studies, it is likely related to inflammation of cardiac tissue caused primarily by macrophages and lymphocytes. Treatment of lyme carditis consists of IV or oral antibiotics such as doxycycline, amoxicillin, or ceftriaxone.

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