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Bradycardia: Difference between revisions
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===Investigations=== | ===Investigations=== | ||
There are a number of additional investigations which can uncover the cause of bradyarrhythmias. | There are a number of additional investigations which can uncover the cause of bradyarrhythmias. | ||
* ECG: A surface ECG can demonstrate the conduction disorder and relate complaints to electrocardiographic findings. A Valsalva manoeuvre or carotid sinus massage whilst performing an ECG can give information about function of the autonomous nervous system and its possible role in the occurrence of the bradyarrrhythmia. | * <b>ECG:</b> A surface ECG can demonstrate the conduction disorder and relate complaints to electrocardiographic findings. A Valsalva manoeuvre or carotid sinus massage whilst performing an ECG can give information about function of the autonomous nervous system and its possible role in the occurrence of the bradyarrrhythmia. | ||
* X-ECG: An exercise test can give information about the chronotropic competence of the cardiac conduction system. | * <b>X-ECG:</b> An exercise test can give information about the chronotropic competence of the cardiac conduction system. | ||
* Long-term ECG recording: Holter recording can identify causes of paroxysmal or intermittent bradyarrhythmias. Importantly a correlation with symptoms can be made and pathological causes of bradyarrhythmias or long pause (>3sec) during the night can be identified. If 24h or 48h Holter recordings cannot identify the cause of symptoms longer duration of monitoring may be required. Transient event recorders can record up to 30seconds of ECG when a patient activates the device. This device can be especially useful when non-invasive monitoring is required due to the low occurrence of the bradyarrhythmia. For longer monitoring an implantable loop recorder can be used. This small device can be implanted and observe rhythm over an extensive period. | * <b>Long-term ECG recording:</b> Holter recording can identify causes of paroxysmal or intermittent bradyarrhythmias. Importantly a correlation with symptoms can be made and pathological causes of bradyarrhythmias or long pause (>3sec) during the night can be identified. If 24h or 48h Holter recordings cannot identify the cause of symptoms longer duration of monitoring may be required. Transient event recorders can record up to 30seconds of ECG when a patient activates the device. This device can be especially useful when non-invasive monitoring is required due to the low occurrence of the bradyarrhythmia. For longer monitoring an implantable loop recorder can be used. This small device can be implanted and observe rhythm over an extensive period. | ||
* Electrophysiological testing: If non-invasive testing does not discover the bradyarrhythmia underlying the symptoms and electrophysiologic study may be undertaken to assess sinus nodal function and atrioventricular conduction. The measurement of conduction intervals and reaction to standard electrophysiological pacing protocols can elucidate the cause of bradyarrhtyhmia. | * <b>Electrophysiological testing:</b> If non-invasive testing does not discover the bradyarrhythmia underlying the symptoms and electrophysiologic study may be undertaken to assess sinus nodal function and atrioventricular conduction. The measurement of conduction intervals and reaction to standard electrophysiological pacing protocols can elucidate the cause of bradyarrhtyhmia. | ||
=Treatment= | =Treatment= | ||
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===Device Therapy=== | ===Device Therapy=== | ||
Implantable pacemakers activate cardiac myocardium with electrical stimulation, leading to muscle contraction. Due to the nature of a pacemaker, the activation is different from the physiological conduction system, there are electrical and mechanical consequences. It is therefore important to adjust pacemaker setting to the individual patient. The type of pacemakers and their settings are extensively covered in the device chapter of cardiac arrhythmias. The indications for pacemaker implantation in patients with bradyarrhythmias are mentioned below. | Implantable pacemakers activate cardiac myocardium with electrical stimulation, leading to muscle contraction. Due to the nature of a pacemaker, the activation is different from the physiological conduction system, there are electrical and mechanical consequences. It is therefore important to adjust pacemaker setting to the individual patient. The type of pacemakers and their settings are extensively covered in the device chapter of cardiac arrhythmias. The indications for pacemaker implantation in patients with bradyarrhythmias are mentioned below. | ||
* <b>Sinus node disease:</b> | * <b>Sinus node disease:</b> Pacemaker implantation should be considered in patients with sinus node disease which manifests as symptomatic bradycardia in which the symptom-rhythm correlation must have been 1) spontaneously occurring or 2) drug-induced where alternative drug therapy is lacking. Furthermore other eligible candidates for permanent pacing are patients with syncope with sinus node disease, either spontaneously occurring or induced at electrophysiological study and sinus node disease manifests as symptomatic chronotropic incompetence which is 1) spontaneously occurring or 2) drug-induced where alternative drug therapy. | ||
Pacemaker implantation should be considered in patients with sinus node disease which manifests as symptomatic bradycardia in which the symptom-rhythm correlation must have been 1) spontaneously occurring or 2) drug-induced where alternative drug therapy is lacking. Furthermore other eligible candidates for permanent pacing are patients with syncope with sinus node disease, either spontaneously occurring or induced at electrophysiological study and sinus node disease manifests as symptomatic chronotropic incompetence which is 1) spontaneously occurring or 2) drug-induced where alternative drug therapy. | |||
Patients with sinus node disease without symptoms including use of bradycardia-provoking drugs, ECG findings of sinus node dysfunction with symptoms not due directly or indirectly to bradycardia or symptomatic sinus node dysfunction where symptoms can reliably be attributed to non-essential medication do not have an indication for permanent pacemaker therapy. | Patients with sinus node disease without symptoms including use of bradycardia-provoking drugs, ECG findings of sinus node dysfunction with symptoms not due directly or indirectly to bradycardia or symptomatic sinus node dysfunction where symptoms can reliably be attributed to non-essential medication do not have an indication for permanent pacemaker therapy. | ||
* <b>Atrioventricular Block:</b> | * <b>Atrioventricular Block:</b> The following patients with AV conduction block have an indication for pacemaker therapy; 1) chronic symptomatic third or second degree (Mobitz I or II) atrioventricular block 2) neuromuscular diseases (e.g. myotonic muscular dystrophy, Kearns–Sayre syndrome, | ||
The following patients with AV conduction block have an indication for pacemaker therapy; 1) chronic symptomatic third or second degree (Mobitz I or II) atrioventricular block 2) neuromuscular diseases (e.g. myotonic muscular dystrophy, Kearns–Sayre syndrome, | |||
etc.) with third-degree or second-degree atrioventricular Block or 3) third or second degree (Mobitz I or II) atrioventricular block after catheter ablation of the atrioventricular junction or after valve surgery when the block is not expected to resolve. Patients with asymptomatic first degree atrioventricular block, asymptomatic second degree Mobitz I with supra-Hisian conduction block or atrioventricular block expected to resolve do not require a pacemaker implantation. | etc.) with third-degree or second-degree atrioventricular Block or 3) third or second degree (Mobitz I or II) atrioventricular block after catheter ablation of the atrioventricular junction or after valve surgery when the block is not expected to resolve. Patients with asymptomatic first degree atrioventricular block, asymptomatic second degree Mobitz I with supra-Hisian conduction block or atrioventricular block expected to resolve do not require a pacemaker implantation. | ||
* <b>Intraventricular conduction Block:</b> | * <b>Intraventricular conduction Block:</b> Patient which show a intermittent third-degree atrioventricular block, second-degree Mobitz II atrioventricular block. alternating bundle branch block or findings on electrophysiological study of markedly prolonged His-Ventrical interval (≥100ms) or pacing-induced infra-His block in patients with symptoms have an indication for pacemaker therapy. Patients with a bundle branch block without atrioventricular block or symptoms and bundle branch block with first-degree atrioventricular block without symptoms should not have a pacemaker implanted. | ||
Patient which show a intermittent third-degree atrioventricular block, second-degree Mobitz II atrioventricular block. alternating bundle branch block or findings on electrophysiological study of markedly prolonged His-Ventrical interval (≥100ms) or pacing-induced infra-His block in patients with symptoms have an indication for pacemaker therapy. Patients with a bundle branch block without atrioventricular block or symptoms and bundle branch block with first-degree atrioventricular block without symptoms should not have a pacemaker implanted. | |||