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Atrioventricular Dissociation: Treatment & Medication
Updated: Aug 9, 2006
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Treatment depends on the underlying condition and its severity. The important considerations and steps in the treatment of patients with AV dissociation include the hemodynamic status of the patient and recognition of the underlying pathology.
- For patients who are hemodynamically unstable, i.e., patients with ventricular tachycardia, the initial treatment of choice is direct-current cardioversion or intravenous drug therapy, depending on the stability of the patient. Treatment of digoxin toxicity should also be pursued.
- Ascertaining if AV conduction is intact is important in patients with AV dissociation due to an accelerated junctional rhythm following cardiac surgery. Rarely, patients have complete AV block with an accelerated focus distal to the level of block; when the accelerated focus becomes quiescent, heart block is present.
Surgical Care
A permanent pacemaker is rarely necessary.
Consultations
Patients with unexplained or uncorrected persistent symptomatic AV dissociation due to an escape rhythm or ventricular tachycardia may require referral to an electrophysiologist or a cardiologist.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Anticholinergic agents
Competitive inhibitor at autonomic, postganglionic, and cholinergic receptors.
Atropine Sulfate
Increases heart rate through vagolytic effects, causing increase in cardiac output.
Adult
0.5-1.0 mg IV or ET q3-5min; not to exceed 3 mg total (0.04 mg/kg)
Pediatric
0.02 mg/kg/dose IV; minimum of 0.1 mg
Other anticholinergics have additive effects; may increase pharmacologic effects of atenolol and digoxin; may decrease antipsychotic effects of phenothiazines; tricyclic antidepressants with anticholinergic activity may increase effects
Documented hypersensitivity; thyrotoxicosis; narrow-angle glaucoma; tachycardia
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Avoid in Down syndrome and/or children with brain damage to prevent hyperreactive response; avoid in coronary heart disease, tachycardia, congestive heart failure, cardiac arrhythmias, and hypertension; caution in peritonitis, ulcerative colitis, hepatic disease, and hiatal hernia with reflux esophagitis; in patients with prostatic hypertrophy, prostatism is associated with dysuria and may require catheterization
Adrenergic agonist agents
Stimulate myocardial performance and improve coronary artery blood flow.
Isoproterenol (Isuprel, Isopro)
Has beta1- and beta2-adrenergic receptor activity. Binds beta-receptors of heart, smooth muscle of bronchi, skeletal muscle, vasculature, and alimentary tract. Has positive inotropic and chronotropic actions.
Adult
Dilute 1 mL of 1:5000 solution (0.2 mg) with 10 mL saline solution or D5W for injection
Dose: 2-6 mcg/min IV (1-3 mL of diluted solution)
Alternatively, dilute 10 mL of 1:5000 solution (2 mg) in 500 mL of D5W or dilute 5 mL of 1:5000 solution (1 mg) in 250 mL of D5W and administer 5 mcg/min (1.25 mL/min of diluted solution) to achieve heart rate of 90-100 bpm
Pediatric
Not established
Tricyclic antidepressants may potentiate pressor response of direct-acting vasopressors
Documented hypersensitivity; tachyarrhythmias, tachycardia, or heart block caused by digitalis intoxication; ventricular arrhythmias that require inotropic therapy; angina pectoris
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
May have a deleterious effect on ischemic or failing heart by increasing myocardial oxygen requirements while decreasing effective coronary perfusion; in some patients, presumably with organic disease of AV node and its branches, may paradoxically worsen heart block or precipitate Adams-Stokes attacks; caution in coronary disease, coronary insufficiency, diabetes, hyperthyroidism, and sensitivity to sympathomimetic amines; if heart rate exceeds 110 bpm, may be advisable to decrease infusion rate or temporarily discontinue infusion
Antidotes
Used to treat digitalis intoxication.
Digoxin immune Fab (Digibind)
Immunoglobulin fragment with a specific and high affinity for both digoxin and digitoxin molecules. Removes digoxin or digitoxin molecules from tissue binding sites.
Each vial of Digibind contains 40 mg of purified digoxin-specific antibody fragments that bind approximately 0.6 mg of digoxin or digitoxin. The dose of antibody depends on total body load (TBL) of digoxin; estimates of TBL can be calculated in 3 ways, (1) estimate of the quantity of digoxin ingested in the acute ingestion and assume 80% bioavailability (mg ingested X 0.8 = TBL); (2) obtain a serum digoxin concentration and, using a pharmacokinetics formula, incorporate the volume of distribution (Vd) of digoxin and the patient's body weight in kg (TBL = digoxin serum level [ng/mL] X 6 L/kg X body weight in kg); and (3) use an empiric dose based on average requirements for an acute or chronic overdose in an adult or child.
If the quantity of ingestion cannot be estimated reliably, administer empirically (safest to use the largest calculated estimate); alternatively, be prepared to increase dosing if resolution is incomplete. Please see PDR for more complete information.
Adult
Suggested: 10 and 5 vials IV for acute and chronic toxicity, respectively
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in cardiac and renal failure; hypokalemia may occur following reversal of digoxin intoxication
More on Atrioventricular Dissociation |
| Overview: Atrioventricular Dissociation |
| Differential Diagnoses & Workup: Atrioventricular Dissociation |
Treatment & Medication: Atrioventricular Dissociation |
| Follow-up: Atrioventricular Dissociation |
| Multimedia: Atrioventricular Dissociation |
| References |
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References
Braunwald E. Atrioventricular dissociation. In: Braunwald E, Zipes DP, Libby P, eds. Heart Diseases: A Textbook Of Cardiovascular Medicine. 6th ed. Philadelphia, Pa: WB Saunders Co;. 2001.
Duffield JS, Jacob AJ, Miller HC. Recurrent, life-threatening atrioventricular dissociation associated with toxoplasma myocarditis. Heart. Nov 1996;76(5):453-4. [Medline].
Luzza F, Oreto G. Pseudo-atrioventricular dissociation caused by interpolated ventricular extrasystoles in the presence of dual atrioventricular nodal pathway. Chest. May 1994;105(5):1587-9. [Medline].
Oreto G, Smeets JL, Rodriguez LM, et al. Wide complex tachycardia with atrioventricular dissociation and QRS morphology identical to that of sinus rhythm: a manifestation of bundle branch reentry. Heart. Dec 1996;76(6):541-7. [Medline].
Pick A. A-V dissociation. A proposal for a comprehensive classification and consistent terminology. Am Heart J. Aug 1963;66:147-50. [Medline].
Wagner GS. Atrioventricular dissociation. In: Wagner GSS, Marriott HJ, eds. Marriott's Practical Electrocardiography. 9th ed. Baltimore, Md: Williams & Wilkins;. 1994.
Further Reading
Keywords
atrioventricular dissociation, AV dissociation, A-V dissociation, AV block, A-V block, heart block, complete heart block, bradycardia, tachycardia, AV dyssynchrony, ventricular tachycardia, nonparoxysmal junctional tachycardia, junctional tachycardia, escape junctional rhythm, accelerated idioventricular rhythm
Treatment & Medication: Atrioventricular Dissociation