Case Presentation: Symptomatic - PowerPoint Presentation

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Case Presentation: Symptomatic Bradycardia

Andrew J Seier, MD

PGY-1

HPI

69 year-old female

Presents with 1 week history of generalized weakness, fatigue, dizziness on exertion

Denies shortness of breath, chest pain, palpitations, fever, chills

Seen by PCP in the morning, found to be bradycardic and sent to ER

Now status-post 1 L normal saline bolus, symptoms unchanged

Past Medical History

PMH: hypertension, hyperlipidemia, glaucoma, type-II diabetes

PSH: cholecystectomy, appendectomy, OS

iridotomy

(glaucoma), resection of brain tumor (34 years ago)

SH: never smoker, occasional 1-2 drinks of alcohol, no drug use

FH: father unknown, mother alive with diabetes (age 85)

Physical Exam

Vitals: BP 100s-150s/40s-100s, saturating 95% on room air, afebrile, bradycardic in the high 30s-40s

General: An alert, well-nourished, well-developed female in no acute distress

Neck: No JVD, no carotid bruits.

Respiratory: Clear to auscultation throughout.

Cardiac: Bradycardia, S1/S2 heard, grade II/VI crescendo-decrescendo

midsystolic

murmur; dizzy when rising to standing position without significant increase in HR, trace bilateral lower extremity edema.

Neuro:

Nonfocal

.

Labs/Imaging

Chemistry: unremarkable apart from AKI (baseline 0.8, now 1.21)

CBC within normal limits

Troponins: 27, 25, 34

BNP 603

Chest x-ray: unremarkable, no cardiomegaly

EKG

Hospital Course

Cardiology consulted, recommends pacemaker placement

Hospital day 4, right-sided DDD pacemaker (dual chamber paced/sensed/response) is placed

Patient’s symptoms immediately resolve

Discharged home the following day

Repeat EKG

Indications for Permanent Pacing

Andrew J Seier, MD

PGY-1

Pacing Indication Evidence

Drawn from:

2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction

Delay

Class I

– Permanent

pacing is definitely beneficial, useful, and

effective; provided

that the condition is not due to a transient cause.

Class

II

– Permanent

pacing may be indicated but there is conflicting evidence and/or divergence of opinion

;

Class IIA: the

weight of evidence/opinion is in favor of

usefulness/efficacy

Class IIB: usefulness/efficacy

is less well established by evidence/opinion.

Class

III

– Permanent

pacing is not useful/effective and in some cases may be

harmful

.

What is not an indication for permanent pacing? (Class III)

Syncope of undetermined etiology

Asymptomatic

Sinus bradycardia

Sinoatrial block, sinus arrest

Prolonged RR interval in atrial fibrillation

Bradycardia during sleep

2

nd

degree

Mobitz

type 1

RBBB with left axis deviation

AV block or long-QT due to reversible causes

Indications in sinus node dysfunction

Class I

Symptomatic sinus bradycardia or chronotropic incompetence

Sinus node dysfunction due to necessary guideline-directed management and therapy, for which there is no alternative

Class II

Sinus bradycardia and symptomatic, without a clear link between bradycardia and symptoms

Sinus node dysfunction and unexplained syncope

Minimally symptomatic non-elite athlete with rate <40 while awake

Indications in acquired AV block, Class I

Complete AV block

Advanced 2

nd

degree AV block (2 or more consecutive P waves not conducted)

Symptomatic 2

nd

degree AV block

Mobitz

type 1 or 2

2

nd

degree AV block,

Mobitz

2 with wide QRS or

bifascicular

block

Exercise-induced 2

nd

or 3

rd

degree AV block

Indications in acquired AV block, Class II

Asymptomatic 2

nd

degree

Mobitz

2 with narrow QRS

1

st

degree AV block with such a long PR interval that hemodynamic compromise exists

Bi- or

trifascicular

block associated with syncope, attributable to transient 3

rd

degree block

AV block pacing algorithm

Other indications

Conduction abnormalities following MI

Some patients with

neurocardiogenic

syncope associated with

cardioinhibitory

/bradycardic events

Congenital complete heart block (e.g. from neonatal lupus)

Myotonic

muscular dystrophy, Kearns-Sayre syndrome,

Erb's

dystrophy, peroneal

muscular

atrophy (Class IIA with 1

st

degree block, Class I with 2

nd

/3

rd

degree block)

Congenital long-QT (usually AICD)

Refractory heart failure (bi-V pacing/cardiac resynchronization therapy)

End