Case History A 45 year old man presents with 1 day history of left sided chest pain, Dizziness and apprehension.

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Case History

A 45 year old man presents with 1 day history of left sided chest pain, Dizziness and apprehension.

He is smokes 10 cigarettes per day and is Diabetic as well, however not compliant with his medications and dietary discretion

On examination, his Blood pressure is 100/60, Heart rate is around 56 beats per minute and Oxygen saturation is 92 percent.

His ECG is shown below :

A. What are the findings in the ECG?

B. What is the most likely Diagnosis?

C. What are the causes of this condition?

D. What is the management of this condition?

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Answers

A. ECG Findings :

Bradycardia .
Varying PR intervals and R-R Intervals .
Diffuse Ischaemic changes in the form of ST segment depression.
Complete AV dissociation, with independent atrial and ventricular rates.

B. Complete Heart block most likely due to diffuse Ischaemic heart Disease.

In complete heart block, there is complete absence of AV conduction, with none of the supraventricular impulses conducted to the ventricles.

The perfusing rhythm is maintained by junctional or ventricular escape rhythm.

Alternatively, the patient may suffer ventricular standstill leading to syncope (if self-terminating) or sudden cardiac death (if prolonged).

Complete heart block is essentially the end point of either Mobitz I or Mobitz II AV block
It may be due to progressive fatigue of AV nodal cells as per Mobitz I (e.g. secondary to increased vagal tone in the acute phase of an inferior MI).

Alternatively, it may be due to sudden onset of complete conduction failure throughout the His-Purkinje system, as per Mobitz II. This can be secondary to septal infarction in acute anterior MI, or as a result of progression of conducting system disease causing true trifascicular block.

The former is more likely to respond to atropine and has a better overall prognosis.

C. Causes

The causes are the same as for Mobitz I and Mobitz II second degree heart block. The most important aetiologies are:

Inferior myocardial infarction.

AV-nodal blocking drugs (e.g. calcium-channel blockers, beta-blockers, digoxin).

Idiopathic degeneration of the conducting system (Lenegre’s or Lev’s disease), causing true trifascicular block.

Differential diagnosis:

Complete heart block should not be confused with:

High grade AV block: A type of severe second degree heart block with a very slow ventricular rate but still some evidence of occasional AV conduction.

AV dissociation: This term indicates only the occurrence of independent atrial and ventricular contractions and may be caused by entities other than complete heart block (e.g. “interference-dissociation” due to the presence of a ventricular rhythm such as AIVR or VT).

D. Management 

Complete heart block, also known as third-degree atrioventricular (AV) block, is a medical emergency that requires immediate treatment.

 Management of complete heart block includes: 

 

Rapid transport: Patients should be transported to the nearest facility and receive advanced life support (ACLS) with continuous cardiac monitoring. 

 

Assess symptoms and vital signs: Look for signs of compromised peripheral perfusion. 

 

Determine the level of the block: Treatment depends on the level of the block. 

 

Withdraw causative medications: Stop any medications that may be causing or aggravating the heart block. 

 

Pacing: Transcutaneous pacing is the preferred treatment for symptomatic patients. If that doesn't work, a transvenous pacemaker may be needed. 

 

Permanent pacemaker or ICD: Most patients will need a permanent pacemaker or an implantable cardioverter-defibrillator (ICD) if the heart block can't be treated otherwise. 

 

Anti-arrhythmic drugs: These drugs can help prevent abnormal heart rhythms. 

 

Follow-up study: A follow-up study may be performed to ensure the medication is working properly.

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