Pediatric Second-Degree Atrioventricular Block Clinical Presentation

  • Author: M Silvana Horenstein, MD; more...
 
Updated: Jan 27, 2012
 

History and Physical Examination

In patients with second-degree atrioventricular (AV) block, a detailed history is important to estimate the severity of the block, the need for further testing, and possible interventions. A familial history of rhythm disturbances should be sought.

Children in whom second-degree AV block is identified may present with a history of syncope (ie, fainting), presyncope (ie, dizziness), or palpitations, or it may simply be identified during a physical examination because of the irregular pulse.

In case of a syncopal episode, its severity should be assessed, including any associated injury or need for resuscitation. A detailed history of associated illnesses or symptoms should be obtained, as well as family history, maternal illness, travel history, drug ingestion, or toxic exposure.

High vagal autonomic tone may correlate with second-degree Mobitz I (Wenckebach) AV block, as well as possible vasodepressor reaction, as a cause for dizziness or syncope.

According to each subtype of second-degree AV block, the following clinical history may be elicited. In general, patients with Mobitz I (Wenckebach) AV block are asymptomatic. Sometimes, Mobitz I (Wenckebach) AV block is secondary to increased vagal tone, such as in athletes.

Patients with Mobitz II (non-Wenckebach) AV block may also be asymptomatic; however, they should be followed periodically because of the possibility of development of third-degree AV block (complete AV block) with cardiovascular syncope or Stokes-Adams attacks. These patients may also be at risk for sudden death.

Physical examination

The most prominent physical finding is usually that of an irregular pulse, typically with the impression of dropped or skipped beats. Secondary signs of heart failure or low cardiac output should be assessed, including blood pressure, apical impulse, hepatomegaly, and peripheral edema.

Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

M Silvana Horenstein, MD  Assistant Professor, Department of Pediatrics, University of Texas Medical School at Houston; Medical Doctor Consultant, Legacy Department, Best Doctors, Inc

M Silvana Horenstein, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, and American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Robert Murray Hamilton, MD, MSc, FRCPC  Section Head, Electrophysiology, Senior Associate Scientist, Physiology and Experimental Medicine, Labatt Family Heart Centre; Professor, Department of Pediatrics, University of Toronto Faculty of Medicine

Robert Murray Hamilton, MD, MSc, FRCPC is a member of the following medical societies: American Heart Association, Canadian Cardiovascular Society, Canadian Medical Association, Canadian Medical Protective Association, Cardiac Electrophysiology Society, Heart Rhythm Society, Ontario Medical Association, Pediatric Electrophysiology Society, Royal College of Physicians and Surgeons of Canada, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

Charles I Berul, MD Professor of Pediatrics and Integrative Systems Biology, George Washington University School of Medicine; Chief, Division of Cardiology, Children's National Medical Center

Charles I Berul, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, Cardiac Electrophysiology Society, Heart Rhythm Society, Pediatric and Congenital Electrophysiology Society, and Society for Pediatric Research

Disclosure: Johnson & Johnson Consulting fee Consulting

Alvin J Chin, MD Professor of Pediatrics, University of Pennsylvania School of Medicine; Attending Physician, Cardiology Division, Children's Hospital of Philadelphia

Alvin J Chin, MD, is a member of the following medical societies: American Association for the Advancement of Science, American Heart Association, and Society for Developmental Biology

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References

  1. Berdajs D, Schurr UP, Wagner A, Seifert B, Turina MI, Genoni M. Incidence and pathophysiology of atrioventricular block following mitral valve replacement and ring annuloplasty. Eur J Cardiothorac Surg. May 14 2008;[Medline].

  2. Suda K, Raboisson MJ, Piette E, Dahdah NS, Miro J. Reversible atrioventricular block associated with closure of atrial septal defects using the Amplatzer device. J Am Coll Cardiol. May 5 2004;43(9):1677-82. [Medline].

  3. Khongphatthallayothin A, Chotivitayatarakorn P, Somchit S. Morbitz type I second degree AV block during recovery from dengue hemorrhagic fever. Southeast Asian J Trop Med Public Health. Dec 2000;31(4):642-5. [Medline].

  4. Costedoat-Chalumeau N, Georgin-Lavialle S, Amoura Z, Piette JC. Anti-SSA/Ro and anti-SSB/La antibody-mediated congenital heart block. Lupus. 2005;14(9):660-4. [Medline].

  5. Chang YL, Hsieh PC, Chang SD. Perinatal outcome of fetus with isolated congenital second degree atrioventricular block without maternal anti-SSA/Ro-SSB/La antibodies. Eur J Obstet Gynecol Reprod Biol. Oct 1 2005;122(2):167-71. [Medline].

  6. Vantyghem MC, Pigny P, Maurage CA, Rouaix-Emery N, Stojkovic T, Cuisset JM, et al. Patients with familial partial lipodystrophy of the Dunnigan type due to a LMNA R482W mutation show muscular and cardiac abnormalities. J Clin Endocrinol Metab. Nov 2004;89(11):5337-46. [Medline].

  7. Payne CE, Usher BW. Atrioventicular block in familial amyloidosis; revisiting an old debate. J S C Med Assoc. Jun 2007;103(5):119-22. [Medline].

  8. Cui G, Kobashigawa J, Margarian A. Cause of atrioventricular block in patients after heart transplantation. Transplantation. Jul 15 2003;76(1):137-42. [Medline].

  9. Niwa K, Warita N, Sunami Y. Prevalence of arrhythmias and conduction disturbances in large population-based samples of children. Cardiol Young. Feb 2004;14(1):68-74. [Medline].

  10. Massin MM, Bourguignont A, Gérard P. Study of cardiac rate and rhythm patterns in ambulatory and hospitalized children. Cardiology. 2005;103(4):174-9. [Medline].

  11. Zhao H, Cuneo BF, Strasburger JF, Huhta JC, Gotteiner NL, Wakai RT. Electrophysiological characteristics of fetal atrioventricular block. J Am Coll Cardiol. Jan 1 2008;51(1):77-84. [Medline].

  12. Nagashima M, Matsushima M, Ogawa A, et al. Cardiac arrhythmias in healthy children revealed by 24-hour ambulatory ECG monitoring. Pediatr Cardiol. 1987;8(2):103-8. [Medline].

  13. Fernandez P, Corfield VA, Brink PA. Progressive familial heart block type II (PFHBII): a clinical profile from 1977 to 2003. Cardiovasc J S Afr. May-Jun 2004;15(3):129-32. [Medline].

  14. Horigome H, Nagashima M, Sumitomo N, et al. Clinical characteristics and genetic background of congenital long-QT syndrome diagnosed in fetal, neonatal, and infantile life: a nationwide questionnaire survey in Japan. Circ Arrhythm Electrophysiol. Feb 1 2010;3(1):10-7. [Medline].

  15. Ruffatti A, Milanesi O, Chiandetti L, et al. A combination therapy to treat second-degree anti-ro/la-related congenital heart block. a strategy to avoid stable third-degree heart block?. Lupus. Dec 20 2011;[Medline].

  16. Wilkoff BL, Auricchio A, Brugada J, et al. HRS/EHRA Expert Consensus on the Monitoring of Cardiovascular Implantable Electronic Devices (CIEDs): description of techniques, indications, personnel, frequency and ethical considerations: developed in partnership with the Heart Rhythm Society (HRS) and the European Heart Rhythm Association (EHRA); and in collaboration with the American College of Cardiology (ACC), the American Heart Association (AHA), the European Society of Cardiology (ESC), the Heart Failure Association of ESC (HFA), and the Heart Failure Society of America (HFSA). Endorsed by the Heart Rhythm Society, the European Heart Rhythm Association (a registered branch of the ESC), the American College of Cardiology, the American Heart Association. Europace. Jun 2008;10(6):707-25. [Medline].

 
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A common pattern of second-degree atrioventricular (AV) block consists of gradual prolongation of the PR interval leading up to a nonconducted P wave; this pattern is known as Wenckebach AV block, or Mobitz I AV block. This rhythm strip is an example of classic Mobitz I, or Wenckebach, AV block, in which the PR interval prolongs by sequentially smaller increments, with consequent shortening of the RR intervals until the blocked beat occurs. However, classic Wenckebach block is present in only a minority of cases. Wenckebach block is most easily diagnosed by comparing the PR interval following the blocked beat with the PR interval preceding the blocked beat; if the PR interval shortens following the blocked beat, the block is most likely of the Wenckebach type.
If the PR interval fails to shorten following a blocked beat, non-Wenckebach AV block (or Mobitz II AV block) is said to be present. This block is usually located more distally in the His bundle or the His bundle branches, or both, and the escape rates are usually slower and less stable.
 
 
 
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