What is the appropriate disposition for patients with AV (Atrioventricular) block type I in the emergency department?

From the Guidelines

Patients with AV block type I can typically be discharged from the emergency department with appropriate follow-up, as progression to advanced AV block is uncommon and pacing is usually not indicated unless the patient is symptomatic. AV block type I is characterized by a progressive prolongation of the PR interval before a nonconducted beat and is usually seen in conjunction with a narrow QRS complex 1. The decision to pace a patient with AV block type I should be based on the presence of symptoms directly attributable to bradycardia, such as syncope, presyncope, chest pain, or palpitations 1.

Some key points to consider in the management of AV block type I include:

• Evaluation for underlying causes such as medication effects, electrolyte abnormalities, or structural heart disease
• Consideration of dose adjustment or discontinuation of medications that may be contributing to the AV block
• Referral for outpatient cardiology follow-up within 1-2 weeks to monitor for progression of the AV block or development of symptoms
• Patient education on warning signs that would necessitate return to the ED, such as syncope, presyncope, chest pain, or palpitations

It is also important to note that the presence of a wide QRS complex or symptoms such as syncope or presyncope may indicate a higher risk of progression to advanced AV block and may necessitate more urgent evaluation and treatment 1. However, in the absence of these factors, a conservative management approach is generally recommended. Overall, the management of AV block type I should be individualized based on the patient's symptoms, underlying medical conditions, and other factors, with a focus on minimizing morbidity, mortality, and improving quality of life 1.

From the FDA Drug Label

Atropine also may lessen the degree of partial heart block when vagal activity is an etiologic factor In some patients with complete heart block, the idioventricular rate may be accelerated by atropine; in others, the rate is stabilized.

The appropriate disposition for patients with AV block type I in the emergency department is not explicitly stated in the provided drug label. However, atropine may be considered to lessen the degree of partial heart block when vagal activity is an etiologic factor 2.

• Key points:
  • Atropine may lessen the degree of partial heart block
  • Atropine's effect on heart block is dependent on the etiology of the block
  • The label does not provide explicit guidance on disposition for AV block type I.

From the Research

Disposition of Patients with AV Block Type I in the Emergency Department

• The disposition of patients with AV block type I in the emergency department depends on various factors, including the presence of symptoms and underlying heart disease 3.
• AV block type I is generally considered to have a benign natural course, and permanent pacing is not typically warranted 3.
• However, patients with second-degree AV block, including type I, can have an ominous course, especially in older patients with underlying heart disease 3.
• The decision to admit or discharge a patient with AV block type I from the emergency department should be based on a thorough evaluation of their clinical condition, including the presence of symptoms, underlying heart disease, and other comorbidities.

Factors Influencing Disposition Decision

• The disposition decision for patients with AV block type I in the emergency department is influenced by various factors, including:
  • Triage and initial assessment 4
  • Diagnostic accuracy and completeness 4
  • Communication between healthcare providers and with patients and their families 4
  • Departmental busyness and crowding 4
  • Clinical gestalt and risk stratification 4
• These factors can contribute to errors in disposition decision-making, highlighting the need for careful consideration and evaluation of each patient's individual circumstances.

Management and Treatment

• Patients with AV block type I who are asymptomatic and have no underlying heart disease can typically be discharged from the emergency department with follow-up appointments for further evaluation and monitoring 3, 5.
• Symptomatic patients or those with underlying heart disease may require admission to the hospital for further evaluation and treatment, including potential pacemaker implantation 6, 3.
• The use of biventricular pacing or other advanced pacing modes may be considered in patients with first-degree AV block and symptoms or underlying heart disease 7.