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A 71 year old female with generalized fatigue (can we add a few more descriptors here)? Presents with the following ECG

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ECG # 2

Criteria for major diagnosis Causes MimickersManagement Other similar examples Button to show answer, diagnostic criteria, +/- teaching points Clinical Vignette Diagnostic criteria index

07 Sinus rhythm 21AV junctional escape complexes 33AV Block, 3° 71 year old female with generalized fatigue Causes Mimickers Management Other similar examples Criteria for major diagnosis Diagnostic criteria index

Diagnostic Criteria: 33 AV Block, 3° Atrial and ventricular rhythms independent of each other (AV dissociation) Variable PR intervals Constant PP and RR intervals; A rate usually faster than V rate Ventricular rhythm maintained by junctional or idioventricular escape rhythm 71 year old female with generalized fatigue Causes Mimickers Management Other similar examples Criteria for major diagnosis Diagnostic criteria index

07 Sinus rhythm Regular Sinus Rhythm Atrial Rate 75 Notice the constant P-P intervals which are not altered by ventricular QRS complex. Causes Mimickers Management Other similar examples Criteria for major diagnosis Diagnostic criteria index 71 year old female with generalized fatigue

21AV junctional escape complexes Narrow QRS complex beats; rate usually per minute This is a secondary phenomenon in response to high grade AV block. There is no relationship of the QRS complexes to the P waves. Causes Mimickers Management Other similar examples Criteria for major diagnosis Diagnostic criteria index 71 year old female with generalized fatigue

Causes MI Drug toxicity (digoxin, beta-blockers, calcium channel blockers) Degeneration of conduction system Post-cardiac surgery Infiltrative diseases Infective endocarditis (esp aortic valve) Lyme disease

Mimickers DiagnosisDifferentiating features 1 st degree AV block Constant PR interval 2 nd degree AV block- Type I Constant PP interval PR interval progressively lengthens until one QRS complex is not conducted (“dropped beat”) Appearance of “grouped beating” on rhythm strip 2 nd degree AV block – Type II Constant PP interval PR interval is constant EXCEPT for non- conducted P wave (“dropped” QRS) AV dissociation Atrial and ventricular rates are different (atrial rate may be slower or faster) PP intervals constant RR intervals constant

Management Continuous monitoring of heart rhythm Discontinue drugs with AV node blocking effect; if taking digoxin, measure serum level For suspected drug toxicity, consider counter-active medications If symptomatic or concern for clinical/hemodynamic worsening, consider transcutaneous or transvenous pacing; may temporize with dopamine, dobutamine, isoprotenernol IV If congenital, evaluate response to exercise

Diagnostic criteria: 3 rd Degree AV Block Atrial and ventricular rhythms independent of each other (AV dissociation) Variable PR intervals Constant PP and RR intervals; A rate usually faster than V rate Ventricular rhythm maintained by junctional or idioventricular escape rhythm

Index of diagnostic criteria AV block, 1 st degree AV block, 2 nd degree, type 1 AV block, 2 nd degree, type 2 AV block, 3 rd degree AV dissociation…