eMedicine Specialties > Cardiology > Arrhythmias

Second-Degree Atrioventricular Block: Treatment & Medication

Author: Ali A Sovari, MD, Clinical and Research Fellow in Cardiovascular Medicine, Section of Cardiology, University of Illinois at Chicago
Coauthor(s): Abraham G Kocheril, MD, FACC, FACP, Professor of Medicine, Director of Clinical Electrophysiology, University of Illinois at Chicago; Raluca B Arimie, MD, Assistant Professor of Internal Medicine, Department of Medicine, Division of Cardiology, University of California at Los Angeles; Consulting Staff, Santa Monica Cardiology; Ryan L Cooley, MD, Consulting Staff, Heart Care Associates LLC, Wisconsin Electrophysiology Group; Assistant Professor, Department of Medicine, University of Wisconsin Medical School at Milwaukee
Contributor Information and Disclosures

Updated: Sep 2, 2009

Treatment

Medical Care

Except for the use of atropine in selected cases of transient AV block, permanent cardiac pacing has replaced medical interventions in the treatment of patients with symptomatic, otherwise untreatable, AV block.

Surgical Care

Indications for permanent pacing in second-degree AV block are explained in detail in ACC/AHA/NASPE and ACC/AHA/HRS guidelines.12,13 A summary of indications is as follows:

  • Second-degree AV block associated with signs such as bradycardia, heart failure, and asystole greater than or equal to 3 seconds
  • Second-degree AV block with neuromuscular diseases, such as myotonic muscular dystrophy, Erb dystrophy, and peroneal muscular atrophy, even in asymptomatic patients (The progression of the block is unpredictable in these patients.) In some of these patients, an ICD may be appropriate.
  • Type II second-degree AV block with wide QRS complexes
  • Asymptomatic type I second-degree AV block with the block at intra- or infra-His level found at electrophysiologic study (level II recommendation)
  • Second-degree AV block may occur following MI, and it may be transient or asymptomatic. In this case, pacemaker placement may not be needed. However, persistent and symptomatic second-degree AV block after MI, especially if it is associated with bundle-branch block needs permanent pacemaker placement. High-grade block after anterior myocardial infarction, even if transient, may warrant permanent pacing.
  • Second-degree AV block following cardiac surgery may be persistent and require pacemaker placement.
  • Second-degree AV block in drug toxicity, Lyme disease, and hypoxia in sleep apnea are expected to resolve. In any situation that second-degree AV is expected to resolve by correction of the underlying pathology, permanent pacemaker placement is not indicated.

Consultations

Cardiac electrophysiologist

Medication

Atropine can be used for immediate treatment of symptomatic second-degree AV block in the AV node. For block in the His-Purkinje system, atropine does not improve conduction and can actually precipitate third-degree AV block by increasing the sinus rate and AV nodal conduction.

Anticholinergic agents

Improve AV nodal conduction in second-degree block at the AV nodal level.


Atropine sulfate injection

Used to increase heart rate through vagolytic effects, causing an increase in cardiac output.

Adult

0.5-1 mg IV or ET q3-5min; not to exceed 3 mg total (0.04 mg/kg)

Pediatric

0.02 mg/kg/dose IV; use a minimum of 0.1 mg

Coadministration with other anticholinergics has additive effects; pharmacologic effects of atenolol and digoxin may increase; antipsychotic effects of phenothiazines may decrease; tricyclic antidepressants with anticholinergic activity may increase effects

Documented hypersensitivity; thyrotoxicosis; narrow-angle glaucoma; tachycardia

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in Down syndrome and/or children with brain damage to prevent hyperreactive response; caution in coronary heart disease, tachycardia, congestive heart failure, cardiac arrhythmias, hypertension, peritonitis, ulcerative colitis, hepatic disease, and hiatal hernia with reflux esophagitis; in prostatic hypertrophy, prostatism can lead to dysuria and may require catheterization

More on Second-Degree Atrioventricular Block

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References
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References

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Further Reading

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Keywords

second-degree atrioventricular block, heart block, 2nd degree heart block, second-degree AV block, 2nd degree AV block, AV block, Mobitz AV block, Mobitz heart block, Mobitz type I, Mobitz type II, Wenckebach phenomenon, Wenckebach heart block, high-grade AV block, complete heart block, third-degree AV block, Stokes-Adams syncopal attack, heart failure, angina, acute myocardial infarction, sinus slowing, cardioactive drugs, endocarditis, myocarditis, Lyme disease, acute rheumatic fever, amyloidosis, hemochromatosis, sarcoidosis, hyperkalemia, hypermagnesemia, Addison disease, ankylosing spondylitis, dermatomyositis, rheumatoid arthritis, scleroderma, lupus erythematosus, Reiter syndrome, progressive idiopathic fibrosis of the cardiac skeleton, aortic stenosis, aortic valve replacement surgery, muscular dystrophies, corrective congenital heart surgery

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Contributor Information and Disclosures

Author

Ali A Sovari, MD, Clinical and Research Fellow in Cardiovascular Medicine, Section of Cardiology, University of Illinois at Chicago
Ali A Sovari, MD is a member of the following medical societies: American College of Physicians and American Heart Association
Disclosure: Nothing to disclose.

Coauthor(s)

Abraham G Kocheril, MD, FACC, FACP, Professor of Medicine, Director of Clinical Electrophysiology, University of Illinois at Chicago
Abraham G Kocheril, MD, FACC, FACP is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, Cardiac Electrophysiology Society, Central Society for Clinical Research, Heart Failure Society of America, and Illinois State Medical Society
Disclosure: Nothing to disclose.

Raluca B Arimie, MD, Assistant Professor of Internal Medicine, Department of Medicine, Division of Cardiology, University of California at Los Angeles; Consulting Staff, Santa Monica Cardiology
Disclosure: Nothing to disclose.

Ryan L Cooley, MD, Consulting Staff, Heart Care Associates LLC, Wisconsin Electrophysiology Group; Assistant Professor, Department of Medicine, University of Wisconsin Medical School at Milwaukee
Ryan L Cooley, MD is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Robert E Fowles, MD, Clinical Professor of Medicine, University of Utah College of Medicine; Consulting Staff, Intermountain Medical Center and LDS Hospital; Director and Consulting Staff, Department of Cardiology, Salt Lake Clinic
Robert E Fowles, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, and American Heart Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Brian Olshansky, MD, Professor of Medicine, Department of Internal Medicine, University of Iowa College of Medicine
Brian Olshansky, MD is a member of the following medical societies: American Autonomic Society, American College of Cardiology, American College of Chest Physicians, American College of Physicians, American College of Sports Medicine, American Federation for Clinical Research, American Heart Association, Cardiac Electrophysiology Society, Heart Rhythm Society, and New York Academy of Sciences
Disclosure: Guidant/Boston Scientific Honoraria Speaking and teaching; Medtronic Honoraria Speaking and teaching; Guidant/Boston Scientific Consulting fee Consulting; Reliant Grant/research funds Other; Novartis Honoraria Speaking and teaching; Novartis Consulting fee Consulting

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Jeffrey N Rottman, MD, Professor of Medicine and Pharmacology, Director, Clinical Cardiac Electrophysiology Fellowship Program, Vanderbilt University School of Medicine; Chief, Department of Cardiology, Nashville Veterans Affairs Medical Center
Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association and North American Society of Pacing and Electrophysiology (NASPE)
Disclosure: Nothing to disclose.

 
 
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