Laboratory Studies
For most patients with illness serious enough to cause third-degree atrioventricular (AV) block (complete heart block), a complete blood cell (CBC) count is indicated to screen for coincident problems (eg, anemia, infection) that may require emergency intervention. The presence of fever or an elevated white blood cell (WBC) count should be evaluated with blood cultures because endocarditis can be complicated by heart block.
Serum concentrations of electrolytes, including potassium and magnesium, should be measured to look for metabolic imbalance, indications of renal insufficiency or failure, and particularly for severe hyperkalemia. The prothrombin time and activated partial thromboplastin time should also be routinely obtained.
A digoxin level should be obtained for patients on digoxin or in whom ingestion of digoxinlike compounds (eg, lily of the valley, oleander, foxglove, Bufonidae toads) is suspected. The same should be done for any other drugs the patient is taking that are capable of causing AV block. Note that the presence of a detectable digoxin level following a nondigoxin cardiac glycoside ingestion can only confirm the presence of such a toxin. The digoxin level does not correlate to the degree of cardiac glycoside toxicity following nondigoxin-induced cardiac glycoside ingestions.
Myocarditis-related laboratory studies should be performed in patients suspected of having myocarditis. Such studies include Lyme titers, human immunodeficiency virus (HIV) serologies, enterovirus polymerase chain reaction (PCR), adenovirus PCR, and Chagas titers, as clinically appropriate.
Lyme titers should be obtained from all patients who may have been exposed to Lyme disease. Because cardiac manifestations of Lyme disease are delayed, Lyme-induced heart block can occur during any season. The decision to perform serologic testing for Lyme disease or any of the collagen vascular diseases depends on other associated history and findings.
Imaging Studies
Radiography
A chest radiograph should be obtained in patients with suspected third-degree atrioventricular (AV) block (complete heart block).
Echocardiography
If the clinical examination findings or patient history suggest cardiomyopathy or valvular disease, then transthoracic echocardiography (TTE) should be performed. Specific etiologies (eg, valve ring abscess) may call for transesophageal echocardiographic (TEE) imaging. A determination of left ventricular function by means of echocardiography or another technique can help in determining whether a pacemaker or defibrillator should be implanted for the treatment of the heart block.
In a study that evaluated the correlations between interventricular mechanical delay (IVMD) and cardiac function in 13 Japanese cases of pediatric isolated complete AV block and epicardial pacing at the left ventricle, right ventricle, or both, investigators found an association between left-sided contraction delay and poor left ventricular contraction and impaired left ventricular synchrony. [21] The investigators noted that the use of IVMD could help stratify patients during follow-up.
Computed tomography (CT) scanning
TTE alone may not be sufficient to detect cardiac and chest abnormalities or correctly identify organic disease in those with second- or third-degree AV block. CT scanning alone or in combination with TTE appears to appropriately identify patients with third- and second-degree AV block but not Wenckebach type. [22]
Electrocardiography
The most important study in patients with suspected third-degree atrioventricular (AV) block (complete heart block) is 12-lead electrocardiography (ECG). On 12-lead ECG, third-degree AV block is characterized by complete lack of conduction (no P waves cause a QRS complex). If complete AV block exists, then the R-R interval is very regular; therefore, before diagnosing third-degree AV block, the R-R interval should be either marched out or measured. If high-grade AV block exists without complete heart block, then some irregularity may occur during intervals following conducted P waves.
As discussed under Etiology, various pathologic conditions can cause conduction system disease and heart block. These systemic or myocardial diseases rarely present as conduction block, with the exception of Lyme disease, inferior myocardial infarction (MI), and some of the neuromuscular diseases. Unless suggested by the patient's history, examination findings, family history, risk factors, or 12-lead ECG findings, the authors do not screen for underlying pathology.
Surface ECG and review of prior ECG data can provide important clues to the level of third-degree AV block. The assessment can begin with a review of the current QRS width and morphology, comparing the QRS during heart block to the QRS when conduction was occurring (see the image below).
Third-Degree Atrioventricular Block (Complete Heart Block). ECG before and after complete heart block at the AV nodal level.
If the QRS is narrow (< 120 msec) during conducted beats and narrow with the same morphology during escape beats, then the block is in the AV junction. If the conducted QRS was narrow at baseline and is wide during the escape rhythm (see the image below), then this is likely a distal level of block located anatomically in the His bundle or in both right and left bundles.
Third-Degree Atrioventricular Block (Complete Heart Block). Complete heart block with wide complex escape.
Other Studies
If the patient's clinical history or 12-lead electrocardiographic (ECG) findings suggest active coronary artery disease, then measurement of cardiac enzyme levels and an evaluation of ischemia, including either cardiac catheterization or stress testing, are needed.
Ambulatory monitoring may be performed to document transient heart block or other bradyarrhythmias in patients presenting with symptoms suggestive of bradycardia.
Diagnostic electrophysiologic studies can be performed to assess atrioventricular (AV) conduction and to discern the level of block (AV nodal or infranodal) when necessary.
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Third-Degree Atrioventricular Block (Complete Heart Block). ECG before and after complete heart block at the AV nodal level.
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Third-Degree Atrioventricular Block (Complete Heart Block). Complete heart block with wide complex escape.
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Third-Degree Atrioventricular Block (Complete Heart Block). Electrocardiogram from patient in complete heart block.
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Third-Degree Atrioventricular Block (Complete Heart Block). Transcutaneous cardiac pacing in a patient with third-degree heart block. Video courtesy of Therese Canares, MD; Marleny Franco, MD; and Jonathan Valente, MD (Rhode Island Hospital, Brown University).
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- Overview
- Presentation
- DDx
- Workup
- Treatment
- Approach Considerations
- Initial Management Considerations
- Atropine and Transcutaneous/Transvenous Pacing
- Pacemaker Implantation for Acquired AV Block in Adults
- Pacemaker Implantation for Chronic Bifascicular Block
- Pacemaker Implantation for AV Block After Acute MI
- Activity Restriction
- Prevention
- Consultations
- Long-Term Monitoring
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- Medication
- Questions & Answers
- Media Gallery
- References
