From the Guidelines
Complete heart block with apical elevation is a medical emergency that requires immediate attention, and the patient should be stabilized with temporary pacing while preparing for permanent pacemaker implantation, as recommended by the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay 1. The patient's condition is critical, and the apical elevation suggests concurrent myocardial infarction, likely affecting the right coronary artery which supplies the AV node.
- Initial management includes:
- Atropine 0.5-1mg IV for symptomatic bradycardia
- Transcutaneous pacing if needed
- Urgent coronary angiography and possible percutaneous coronary intervention
- While awaiting definitive treatment, the patient should be maintained on:
- Continuous cardiac monitoring
- Oxygen if saturation is below 94%
- IV access
- Serial ECGs, cardiac enzymes, and electrolytes
- Medications that may worsen heart block, such as beta-blockers and calcium channel blockers, should be avoided. The combination of complete heart block and ST-segment elevation indicates significant myocardial damage affecting both conduction and contractility, which carries higher mortality risk and requires a dual approach addressing both the conduction abnormality and the underlying ischemia, as supported by the ACC/AHA classification 1 and the guidelines for implantation of cardiac pacemakers and antiarrhythmia devices 1.
From the Research
Complete Heart Block
- Complete heart block (CHB) is a serious medical condition that can be fatal if not treated promptly 2
- It is characterized by a complete disruption of electrical conduction between the atria and ventricles, resulting in an abnormal heart rhythm
Treatment Options
- Permanent pacemaker (PPM) implantation is the standard treatment for CHB, especially in patients with irreversible conduction abnormalities 2
- Dual-chamber pacing is preferred over single-chamber pacing, as it provides physiological benefits and improved symptomatic and prognostic outcomes 3
Complications and Risks
- CHB can occur as a complication of certain medical procedures, such as ablation for atrial flutter 4
- Anterior mitral line ablation carries a risk of complete heart block, especially if the catheter is positioned too close to the His bundle 4
Quality of Life
- Patients with CHB and paroxysmal atrial tachyarrhythmias may experience improved quality of life with dual-chamber pacing, especially with mode switch to DDIR 5
- AV synchrony is better preserved with DDDR pacing, which may result in fewer somatic complaints and improved overall quality of life 5