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    ECG Challenge: It's the Level of the Block that Counts


    Figure 2 below shows a sample from leads V1 and V2 of the patient’s stress ECG at rest (left) and then 4 minutes into a standard Bruce exercise protocol (right).

    The baseline (rest, left) rhythm strip again shows 2:1 AV block with two p-waves in between each QRS complex while with exercise this becomes a 1:1 p-wave to QRS complex relationship. The presumed PR interval in the exercise strip, however, is very long (> 400 msec), and inspection of lead V2 shows it is inscribed before the T-wave, therefore the rhythm with exercise likely is an accelerated junctional rhythm with retrograde p-waves rather than 1:1 antegrade AV node conduction.

    Have we demonstrated a degree of nodal block significant enough to require pacemaker implantation?

    The exercise rhythm strip suggests intact retrograde AV node conduction but does not clearly reveal the status of antegrade AV node conduction. Reversible causes for AV nodal block must be addressed before pacemaker implantation is considered. Therefore the patient’s carvedilol was stopped and reassessment of AV node conduction was performed about 5 days after the initial visit with a repeat resting and stress ECG. Findings were essentially unchanged from the rhythm strips in the previous figures. The patient in the interim remained entirely asymptomatic and expressed an understandable reluctance to consider permanent pacemaker implantation.

    Based on this new iformation, is pacemaker implantation now indicated?

    There still is no strict indication for pacemaker implantation primarily because the patient remains asymptomatic and also because the level of block has not been shown to be below the level of the AV node. The most recent (2012) ACC/AHA/HRS Guidelines for Device-based Therapy of Cardiac Rhythm Abnormalities stress that:

    Permanent pacemaker implantation is not indicated for asymptomatic type I second-degree AV block at the supra-His (AV node) level or that which is not known to be intra- or infra-Hisian.

    The most accurate method to confirm the level of AV block is minimally invasive electrophysiologic (EP) evaluation of AV nodal physiology. This is performed by advancing a diagnostic pacing/mapping electrode catheter to the level of the AV node-HIS bundle region at the superior aspect of the tricuspid valve. Baseline conduction properties of the AV node and HIS bundle are then measured (in Figure 3 below A, H and V represent depolarization of the atrium, HIS bundle, and ventricle, respectively).

    Advanced distal block is suggested if prolonged HIS to ventricular conduction times are noted (typically > 65 msec). An atrial pacing protocol at increasing rates is then performed with close evaluation of conduction to the ventricles to determine if AV block occurs below the level of the HIS (after the HIS signal) which would again demonstrate pathologic rather than physiologic AV block (before the HIS signal). Pathologic second-degree AV block at intra- or infra-His levels found on EP study is a Class IIB indication for pacemaker implantation in asymptomatic patients.

    Case Resolution

    The patient underwent diagnostic EP study as described above. Baseline H-V times were normal and atrial pacing performed at increasing rates demonstrated AV block occurring before the HIS bundle was activated. These conduction study findings were most consistent with type I second-degree AV block occurring at the supra-His (AV node) level without indication for pacemaker implantation. The patient subsequently underwent 4-week ambulatory rhythm monitoring that did not show evidence of high grade sinus or AV node dysfunction and has been happy with the deferral of permanent pacemaker implantation.


    For more information:

    Epstein AE, DiMarco JP, Ellenbogen KA, et al. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. 2013;127:e283-e352


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