CME INDIA Case Presentation by Dr Neeraj, DNB, Med, Jamshedpur.

CME INDIA Case Study:

Patient with giddiness and headaches for 1 day.

What kind of heart block is going on?

Intermittent 2:1 it looks like to me, says Dr Neeraj.

CME INDIA Discussion:

Dr Satish Kumar, President CSI, Jharkhand, Bokaro:

• First deg. A-V dissociation with Mobitz-II Second degree A-V block.
• The Arial rate is approx. 100/m while Ventricular Rate is 50.
• The PR interval looks pretty fixed.
• The QRS complexes are not widened.
• In any case, this is “high degree AV block” and doesn’t appear to be of Ischaemic origin and hence calls for intervention in the form of Pacing.

Dr Neeraj: Is not ventricular rate around 50 and atrial around 100?

Dr D P Khaitan, Cardiologist Physician, Gaya: I do agree Sir. The ventricular rate is somewhat higher -50/mt.

Dr Satish Kumar, Bokaro: In the monitor, there seems some variation of RR and PR

Dr D P Khaitan, Cardiologist Physician, Gaya: On the monitor at times RR interval is variable but with somewhat fixed PR – at times P not seen, might be buried within preceding T. In conclusion, AV node sickness is progressive.

–First degree AV dissociation with fluctuating Mobitz II AV block responsible for variable RR interval.

However, the patient needs pace maker support.

Dr Neeraj: So, sir TPI as of now and PPI is final answer? But sir what could be reason for such av block at age of 42 years? No previous drug history.

Dr D P Khaitan, Cardiologist Physician, Gaya: By this age we have to evaluate for the cause. Difficult to assess whether TPI and PPI – I would prefer PPI

Dr Satish Kumar, Bokaro: Agree sir, if not having Stokes Adams spells, I would prefer TPI to be done just prior to the PPI, as a backup during the procedure. The block tends to worsen during manipulation of the leads.

CME INDIA Learning Points:

• A first-degree AV block is defined by a prolonged P-R interval > 200 ms with no greater degrees of block.
• A second-degree AV block can be further stratified into Mobitz Type I, in which there is a gradual prolongation of the P-R interval in succeeding beats leading to a non-conducted P wave, and Mobitz Type II, in which the P-R intervals for conducted P waves are the same before and after a non-conducted P wave.
• A third-degree AV block, or complete heart block, is when the atrial and ventricular beats are independent of each other (AV dissociation) due to a loss of conduction from the former to the latter.
• Principles of management of AV block are to first assess for grade of block and haemodynamic stability, followed by symptoms and resting heart rate.
• Patients should be methodically assessed for reversible acquired causes such as electrolyte imbalances, myocardial ischaemia, endocrine abnormalities, myocarditis and other inflammatory conditions of the heart, infections and drug therapy.
• In patients with irreversible causes of AV block, indications for permanent pacemaker insertion include symptomatic bradycardia, periods of asystole ≥ 3 seconds, infra-Hisian escape rhythms, escape rhythms < 40 bpm and complete heart block.

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