service de cardiologie hôpital militaire de tunis
TRANSCRIPT
MANAGEMENT OF ASYMPTOMATIC
BRADYCARDIA
Pr. HABIB HAOUALA
Service de Cardiologie
Hôpital militaire de Tunis
DISCLOSURESTATEMENT OF FINANCIAL INTEREST
Grant/research: Medtronic;Sanofi; Novartis
Consulting fees/ honoraria: SJMédical; Boston Scientific
BRADYCARDIA
Asystole Bradycardia < 50 bpm
Borderline 50-60 bpm
Normal (60-100 bpm)
Tachycardia > 100 bpm
Bradycardia < 50 bpm Borderline 50-60 bpm
bradycardia in child
Asymptomatic bradycardia
A condition in which a person has
bradycardia, or a slow heart rhythm, without
any of the classic symptoms of bradycardia
(dizziness, irregular heart beat, chest pain,
shortness of breath, fatigue, and light
headedness…)
Asymptomatic sinus bradycardia is usually
harmless and is often a sign of good
physical condition
Resting heart rate as a predictive
risk factor for sudden death
JOUVEN X Cardiovasc Res. 2001
May;50(2):373-8
Diagnosis of bradycardia
Diagnosis of bradycardia
Diagnosis of bradycardia
Diagnosis of bradycardia
Carecterization of the
bradycardia Mechanism:
◦ Sinus node dysfunction
◦ Brady-arrythmia
◦ Atrio-ventricular block
Frequency
◦ Permanent
◦ Paroxysmal
General evaluation of
bradycardia Clinical evaluation
◦ Symptoms
◦ Drugs
◦ Daily activity
◦ Sports
◦ Familial history of bradycardia
General evaluation of bradycardia
Clinical evaluation
◦ Symptoms
◦ Drugs
◦ Daily activity
◦ Sports
◦ Familial history of bradycardia
Evaluation of the heart◦ Chest X ray
◦ Echocardiography
◦ MRI
◦ CT- Scan
◦ Angiography
Structural heart disease
(Valvular, ischaemic, congenital,
Hypertrophic, Dilated …)
Normal heart
General evaluation of bradycardia
Bradycardia evaluation
24-48 Hours ECG Monitoring
TREADMILL TEST
ATROPINE/ ISUPREL Test
General evaluation of bradycardia
ELECTROPHYSIOLOGY STUDY
Bradycardia evaluation
24-48 Hours ECG Monitoring
• Long pauses
• Supraventricular arrhythmias
• Ventricular arrhythmias
• Chronotropic insufficiency
General evaluation of bradycardia
Bradycardia evaluation
TREADMILL TEST
• Chronotropic
insufficiency
• Good exercise capacity
General evaluation of bradycardia
Bradycardia evaluation
ATROPINE/ ISUPREL Test
General evaluation of bradycardia
Differentiation between intrinsic
and extrinsic bradycardia
ATROPINE/ISOPROTRENOL TEST
Europace. 2008 Oct;10(10):1176-
81
Bradycardia evaluation
General evaluation of bradycardia
ELECTROPHYSIOLOGY STUDY
• Evaluation of sinus node function (Sinus node
recovery delay)
• Evaluation of the AV node conduction ( AH, HV,
LWC)
• Induction of arrhythmias
• May be useful in suspected ( not documented)
bradycardia
SINUS NODE DYSFUNCTION
Clinical case 1
22 years old man
Handball Player
W/H 120 Kgs/ 1,97m
He’s follwing an hypocaloric diet
No symptoms
ECG
Causes of sinus bradycardia
Physiologic extrinsic causes
Intrinsic causes
The athlete's heart
J Physiol. 2015 Apr 15; 593(Pt 8): 1749–1751.
Bradycardia in athletes is attributable to
High vagal tone J Physiol 593.8 (2015) pp 1745–1747
downregulation of a pacemaker
channel in the sinus node J Physiol. 2015 Apr 15; 593(Pt 8): 1749–1751.
Extrinsic causes of bradycardia
Drugs
◦ Digitalis glycosides, beta-blockers, and calcium channel-blocking agents.
◦ class I antiarrhythmic agents and Amiodarone
◦ lithium, paclitaxel, toluene, dimethyl sulfoxide (DMSO), topical ophthalmic
acetylcholine, fentanyl, alfentanil, sufentanil, reserpine, and clonidine
Pathologic conditions
◦ Hypothyroidism
◦ Hypothermia
◦ Hypoglycaemia
◦ Sleep apnoea
Infections
◦ Diphtheria
◦ Rheumatic fever
◦ Viral myocarditis
Intrinsic causes of sinus
bradycardia Sick Sinus Syndrome.
◦ Sinus bradycardia
◦ Sinus arrest
◦ Sino-atrial block
◦ Bradycardia tachycardia syndrome
Familial sinus bradycardia
Milanesi R et al. N Engl J Med 2006;354:151-157.
• Autosmal dominant
• Point mutation in the HCN4 cardiac ion channel
pore
• Genetic testing could play an important role in the
differentiation between benign and mailgnant
forms of familial sinus dysfunction
• Treadmill testing demonstrate normal
chronotropic and excercise capacity
Indications of Pacing in
patients with sinus node
dysfunction
BRADYARRYTHMIAS
Clinical case
84 Years old man
HTA, Type 2 Diabetes
Permanent atrial fibrillation
Moderate dyspnoea (NYHA class II)
No syncope, No dizziness
Sleep apnoea disorder
Sleep apnoea disorder
Long sinus pauses and AV block can
occur during sleep apnea in the
absence of symptoms these
abnormalaties are reversible and do
not require pacing
AV BLOCK
Atrio-ventricular block
Death in patients with untreated
atrioventricular (AV) block is due to:
◦ Heart failure (HF) secondary to low
cardiac output,
◦ Sudden cardiac death caused by
prolonged asystole or bradycardia-
triggered ventricular
tachyarrhythmia.
So, how should we manage
Asymptomatic AV block ?
First step◦ Is the AVB acute (reversible) or chronic
(irreversible) ?
Workup
Clinical evaluation
Drugs
Biology :Troponins, Serology diphtheria Lyme
disease typhoid , thyroid function
Imaging (TTE, MRI)
Coronary angiography
So, how should we manage
Asymptomatic AV block ?
Second step◦ What is the underlying heart disease ?
Structural heart disease
No structural heart disease
Indications of pacing in patients with
persistent bradycardia due to AV
block
Indications of pacing in patients with intermittent
documented bradycardia due to AV block
Asymptomatic chronic high degree/complete AV
block permanent or intermittent without structure
heart disease
Pacing indication in CAVB
A wide QRS escape rhythm, complex
ventricular ectopy, or ventricular dysfunction
I B
ventricular rate less than 55 bpm or with
congenital heart disease and a ventricular rate
less than 70 bpm.
I C
beyond the first year of life with an average
heart rate less than 50 bpm, abrupt pauses
ventricular rate that are 2 or 3 times the basic
cycle length, or associated with symptoms due
to chronotropic incompetence
II a B
in asymptomatic children or adolescents with
an acceptable rate, a narrow QRS complex,
and normal ventricular function. (II b B
II b B
Young people
Congenital AVBOld people
degenerative AVB
Pacemaker is
usually indicated
ACCF/AHA/HRS 2008 Guidelines
Asymptomatic chronic high
degre/complete AV block permanent or
intermittent with structure heart disease
Hypertrophic
cardiomyopathy
Asymptomatic chronic high
degre/complete AV block permanent or
intermittent with structure heart disease
Hypertrophic
cardiomyopathy
Congenital heart disease
Asymptomatic chronic high
degre/complete AV block permanent or
intermittent with structure heart disease
Hypertrophic
cardiomyopathy
Congenital heart disease
Cardiac surgery/ TAVI
Asymptomatic chronic high
degre/complete AV block permanent or
intermittent with structure heart disease
Hypertrophic
cardiomyopathy
Congenital heart disease
Cardiac surgery/ TAVI
Muscular dystrophies
Implantation of
PM is encouraged
Conclusion
Asymptomatic bradycardia is diagnosed fortuitously
It’s often physiologically in athletes
It can be transient or permanent evolving on a paroxysmal or persistent mode
When asymptomatic bradycardia was diagnosed, a workup including heart imaging, ECG monitoring on rest and with exercise should be done to determine :◦ The underlying heart disease
◦ The mechanism exact of the bradycardia
Indication of the cardiac pacing depend on the two above conditions
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