From the Guidelines
For patients with 2nd degree Atrioventricular (AV) block type I, emergency department disposition typically involves observation and possible discharge with outpatient follow-up, as long as the patient is hemodynamically stable and asymptomatic. The 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay emphasizes the importance of symptoms when determining the need for permanent pacing 1. Key considerations for disposition include:
- Hemodynamic stability: Patients who are hemodynamically stable can often be managed conservatively.
- Symptoms: Presence of symptoms such as syncope, pre-syncope, chest pain, or dyspnea warrants further evaluation and possible admission.
- Underlying cause: Identifying and addressing any reversible causes of the AV block is crucial. According to the guideline, permanent pacing is generally recommended only in the presence of symptoms that correlate with atrioventricular block, unless there are conditions associated with progressive atrioventricular conduction abnormalities 1. For asymptomatic patients with 2nd degree AV block type I, discharge with outpatient cardiology follow-up within 1-2 weeks is often appropriate, with instructions to return if symptoms develop or worsen. Continuous cardiac monitoring during observation is essential to detect any progression to higher-degree blocks.
From the Research
Emergency Department Disposition for 2nd Degree AV Block Type I
The emergency department disposition for a patient with 2nd degree Atrioventricular (AV) block type I depends on various factors, including the presence of symptoms, underlying cardiac disease, and the width of the QRS complex.
- Symptomatic Patients: Patients with symptoms such as syncope, dizziness, or chest pain require immediate attention and may need hospital admission for further evaluation and treatment 2, 3.
- Asymptomatic Patients: Asymptomatic patients with 2nd degree AV block type I and a narrow QRS complex can often be discharged home with follow-up appointments for further evaluation and monitoring 4, 5.
- Wide QRS Complex: Patients with a wide QRS complex are more likely to have infranodal block, which may require pacing regardless of symptoms 2, 3.
- Underlying Cardiac Disease: Patients with underlying cardiac disease, such as myocardial infarction, may require more aggressive treatment and hospital admission 6.
Disposition Options
- Hospital Admission: Patients with symptoms, underlying cardiac disease, or a wide QRS complex may require hospital admission for further evaluation and treatment.
- Outpatient Monitoring: Asymptomatic patients with a narrow QRS complex can often be discharged home with outpatient monitoring and follow-up appointments.
- Pacemaker Implantation: Patients with infranodal block or those who are at high risk of progressing to complete AV block may require pacemaker implantation 4, 5.