Atrioventricular Block Treatment & Management

Updated: Nov 14, 2017
  • Author: Chirag M Sandesara, MD, FACC, FHRS; Chief Editor: Jose M Dizon, MD  more...
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Treatment

Approach Considerations

Permanent pacing is the therapy of choice in patients with symptomatic atrioventricular (AV) block with bradycardia.

Temporary transcutaneous or transvenous pacing is required if a slow heart rate (or asystole) caused by AV block requires correction and permanent pacing is not immediately indicated or not available.

Activity restriction

Patients with AV block should have their activities restricted to reduce the risk of injury until they have been properly evaluated and treated.

Consultations

Consultation with a cardiologist and/or cardiac electrophysiologist is indicated in the case of advanced heart block or unexplained syncope. An electrophysiologist must be consulted when invasive electrophysiology testing is needed to determine the level and/or magnitude of the AV block.

 

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Pacemaker Implantation

Pacemaker implantation (or a pacemaker defibrillator if there is ventricular dysfunction) is indicated for symptomatic, irreversible atrioventricular (AV) block. Pacemaker implantation may include ventricular (VVI) or dual chamber (DDD) modes of pacing. Chronic right ventricular (RV) pacing may worsen left ventricular (LV) function. Cardiac resynchronization therapy (CRT) may be necessary in certain cases in which long-term pacing is required with reduced LV function. 

The BLOCK-HF (Biventricular Versus Right Ventricular Pacing in Patients With Left Ventricular Dysfunction and Atrioventricular Block) randomized trial evaluated the effect of CRT in heart failure patients with AV block and found that CRT caused LV reverse remodeling and improved ejection fraction. [21] In addition, CRT pacing reduced mortality and heart failure admissions compared to RV pacing. [21] Based on these findings, for patients with high-degree AV block, CRT pacing therapy could be considered for patients with New York Heart Association (NYHA) functional class I, II, or III symptoms, an ejection fraction below 50%, and when chronic RV pacing is required. However, this study was published after the 2008 pacemaker guidelines [1, 2] and is not currently incorporated into any guidelines.

An electrophysiologist should determine the pacing type and the optimal pacing mode based on the level of block.

 

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Long-Term Monitoring

Patients with asymptomatic first-degree or Mobitz I atrioventricular (AV) block do not require long-term monitoring with repeated rhythm strips/electrocardiograms or an event monitor.

Patients with asymptomatic, intermittent second-degree Mobitz II, high-degree, or third-degree AV block benefit from long-term event monitoring to assess for symptoms, bradycardia, or periods of asystole, as this would affect the timing of pacemaker implantation.

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