What is the appropriate management of a patient with dizziness and a new intraventricular conduction delay (IVCD) on electrocardiogram (EKG) without chest pain?

From the Guidelines

The appropriate management of a patient with dizziness and a new intraventricular conduction delay (IVCD) on EKG without chest pain requires prompt hospitalization for cardiac monitoring and comprehensive evaluation. This patient should be admitted to a telemetry unit or cardiac care unit for continuous cardiac monitoring, as the combination of dizziness and new IVCD raises concern for potential cardiac conduction disease that could progress to complete heart block or other life-threatening arrhythmias, as suggested by the 2019 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay 1.

Initial Evaluation

Initial workup should include:

• Serial cardiac enzymes (troponin at 0,3, and 6 hours)
• Complete blood count
• Comprehensive metabolic panel
• Thyroid function tests
• A transthoracic echocardiogram to assess for structural heart disease or reduced ejection fraction, as patients with IVCD on ECG have an increased risk of left ventricular systolic dysfunction compared with those with completely normal ECGs 1.

Cardiology Consultation

Cardiology consultation should be obtained promptly to evaluate the need for temporary or permanent pacemaker placement, considering that an EPS may provide acute diagnostic information and predict a higher risk for complete heart block in patients with fascicular or bundle branch block 1.

Management of Hemodynamic Instability

If the patient is hemodynamically unstable with hypotension, atropine 0.5mg IV (may repeat to maximum 3mg) can be administered while preparing for transcutaneous or transvenous pacing. The urgency of this management approach is justified by the risk of progression to complete heart block, which can cause Stokes-Adams attacks (syncope), hemodynamic compromise, and sudden cardiac death, even in the absence of chest pain, as the new conduction abnormality may represent cardiac ischemia, infiltrative disease, or other progressive cardiac pathology requiring immediate intervention.

Additional Diagnostic Considerations

Additional diagnostic considerations may include ambulatory electrocardiographic monitoring to document clinically significant arrhythmias, and cardiac MRI in selected patients where sarcoidosis, connective tissue disease, myocarditis, or other dilated cardiomyopathies are suspected on clinical grounds, as cardiac MRI can detect subclinical cardiomyopathy in patients with asymptomatic IVCD and a normal echocardiogram 1.

From the Research

Appropriate Management of a Patient with Dizziness and New IVCD on EKG

The management of a patient with dizziness and a new intraventricular conduction delay (IVCD) on electrocardiogram (EKG) without chest pain involves several considerations.

• The presence of IVCD can be a sign of underlying cardiac or non-cardiac conditions, and its significance can vary widely depending on the clinical context 2.
• A study found that IVCDs, such as left bundle branch block (LBBB) and non-specific IVCD, are associated with an increased risk of new-onset heart failure and structural heart disease 3.
• Another study found that IVCD was not an independent risk factor for all-cause mortality in individuals without ischemic heart disease 4.
• The effect of left ventricular conduction delay on all-cause and cardiovascular mortality was studied, and it was found that left ventricular conduction delay (LVCD) was strongly associated with increased mortality in patients with and at-risk for cardiovascular disease 5.
• The impact of antihypertensive therapy on the development of incident conduction system disease in hypertensive patients was also studied, and it was found that losartan-based treatment was associated with a reduced risk of new intraventricular conduction delay (IVCD) 6.

Key Considerations

• The clinical context and underlying conditions of the patient should be taken into account when managing a patient with IVCD and dizziness.
• Further evaluation and monitoring may be necessary to determine the cause of the IVCD and to assess the patient's risk for cardiovascular disease.
• The patient's symptoms, medical history, and other factors should be considered when determining the appropriate management strategy.
• The presence of IVCD should alert clinicians to the possibility of underlying cardiac or non-cardiac conditions, even in patients without known heart disease 3.