Heart Block

Heart Block
Conducting System of Heart

Atrioventricular block
• Delay or interruption in the transmission of an impulse, either
transient or permanent, from the atria to the ventricles due to
an anatomic or functional impairment in the conduction
system
• Common causes:
– myocardial ischemia,
– aging and fibrosis,
– cardiac infiltrative diseases,
– High vagal tone(10%)
Etiologies
Types:
• There are three forms:
– First-degree AV block
– Second-degree AV block
– Third-degree (complete) AV block
First-degree AV block
• Prolongation of the PR interval: >0.20 s but constant
• Every atrial depolarization followed by conduction to the
ventricles but with delay
• Rarely causes symptoms
• Longer PR interval (>5sec)
ECG showing first-degree atrioventricular

block with a prolonged PR interval
Second-degree AV block
• Intermittent failure of electrical impulse conduction
• Sub-classification:
– Mobitz I block (Wenckebach block phenomenon)
– Mobitz II block
(2 : 1 or 3 : 1 (advanced) block)
Mobitz I Block
• Impaired conduction of AV node
• Progressive PR interval prolongation until a P wave fails to
conduct
• Physiological during rest or sleep in young athletes with high
vagal tone
Wenckebach Phenomenon
• PR interval before the blocked P wave much
longer than the PR interval after the blocked P
wave
Mobitz II block
• Impaired conduction in distal or infra-His conduction system
• PR interval of conducted impulse remains constant but some P
waves not conducted
• Usually the QRS complex is wide (> 0.12 s)
• Risk of progression to complete heart block is greater
2:1 block
• After each conducted P wave, alternate wave is

dropped.
• It becomes impossible to differentiate Mobitz type I
and II as PR interval time can’t be noted as constant
or not.
• vagal stimulation and carotid sinus massage:
– slow conduction in the AV node but have less of
an effect on infranodal tissue
• Conversely, atropine, isoproterenol, and
exercise
– improve conduction through the AV node and
impair infranodal conduction.
• His bundle electrogram
Third-degree (complete) AV block
• Occurs when all atrial activity fails to conduct to the ventricles
• Complete disassociation of atrial and ventricular electrical
activity
• In this situation life is maintained by a spontaneous escape
rhythm
• Ventricular activity maintained by escape rhythm arising in
• AV node or bundle of His (narrow QRS)
• Purkinje fibers (wide QRS)
Escape rhythm
Narrow complex escape rhythm Broad complex escape rhythm
– < 0.12 s QRS complex – QRS complex > 0.12 s
– Originates in the His – Originates below the His
bundle bundle
– Region of block lies more – Region of block lies
proximally in the AV node more distally in the His–
– Rate is 50–60 bpm Purkinje system
– Relatively reliable – Rhythm is slow (15–40
bpm)
– Relatively unreliable
Features:
• Large-volume pulse (compensatory increase in stroke volume)
• Cannon waves may be seen in neck
• Intensity of S1 varies
Causes of CHB
Clinical features: Third degree Heart Block
• Typical presentation: recurrent syncope or ‘Stokes Adams’

attacks
– Characterized by sudden LoC that occurs without
warning and results in collapse
– A brief anoxic seizure (due to cerebral ischaemia) may
occur if there is prolonged asystole
– There is pallor and a death-like appearance during the
attack
– When the heart starts beating again there is a
characteristic flush
Treatment
• First-degree AV block and Mobitz I second-degree AV block:
• Not require treatment unless cause symptoms
• Symptomatic second- or third-degree AV block, respond to
• Atropine (0.6 mg IV, repeated as necessary)
• If this fails, a temporary pacemaker
• In most cases, the AV block will resolve within 7–10 days
• Second- or third-degree AV heart block complicating acute

anterior MI: carries a poor prognosis
Acute Inferior MI with AV block
• Occurs because right coronary artery (RCA) supplies the AV
node
• Symptomatic second- or third-degree AV block may respond

to ATROPINE (0.6 MG IV, repeated as necessary)
– If this fails, a temporary pacemaker.
• In most cases, the AV block will resolve within 7–10 days

Acute Anterior MI with 2nd or 3rd
degree AV block
• Indicates extensive ventricular damage involving both bundle
branches
• Asystole may ensue and temporary pacemaker should be inserted
promptly.
• If the patient presents with asystole
– IV atropine (3 mg) or
– IV isoprenaline (2 mg in 500 mL 5% dextrose, infused at 10–60
mL/ hr)
– Help to maintain the circulation until a temporary pacing
electrode can be inserted
– External (transcutaneous) pacing for temporary rhythm support
Chronic AV block
• Pacemaker implantation should be performed in any patient
with
• symptomatic bradycardia
• irreversible second- or third-degree AV block
• Mobitz type II second- or third-degree AV heart block

– risk of asystole and sudden death
– permanent pacemaker is usually indicated
– pacing improves prognosis
Pacemaker implantation
References
– Ralston SH, Penman ID, Strachan MW.J., Hobson RP. (eds).
Davidson’s Principles and Practice of Medicine, 23rd edn.
Edinburgh: Elsevier Ltd; 2018.
– Jameson JL, Kasper DL, Longo DL, Fauci AS, Hauser SL,
Loscalzo J. (eds). Harrison’s Principles of Internal Medicine.
20th edn. New York: Mc Graw –Hill Education; 2018.
– Sajjan M. Learn ECG in a day. 1st edn. New Delhi: Jaypee

brothers medical publishers (P)Ltd; 2013.
• Davidson’s Principle and Practice of Medicine, 22nd edition
Thank you

Heart Block

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What are the different types of atrioventricular block?

What are the characteristics of Mobitz type I and type II block?

Heart Block

Conducting System of Heart

ECG showing first-degree atrioventricular

• After each conducted P wave, alternate wave is

• Typical presentation: recurrent syncope or ‘Stokes Adams’

• Second- or third-degree AV heart block complicating acute

• Symptomatic second- or third-degree AV block may respond

• In most cases, the AV block will resolve within 7–10 days

• Mobitz type II second- or third-degree AV heart block

– Sajjan M. Learn ECG in a day. 1st edn. New Delhi: Jaypee

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