PACEMAKER

Question 1

General Approach

Answer 1

Determine:
Association of symptoms with bradycardia
Location of the conduction abnormality
Absence of a reversible cause

Question 2

Symptoms of Bradyarrhythmias

Answer 2

Dizziness, lightheadedness, syncope, fatigue, poor exercise tolerance

Question 3

Location of Conduction Abnormality: AV Node vs. Below AV Node

Answer 3

AV Node: Primary AV Block with Significant PR Prolongation, Second Degree AV Block Mobitz I, Normal QRS

Below AV Node: Normal or Minimally prolong PRn Second Degree AV Block Mobitz II, Thrid Degree (Complete), Widening of QRS: BBB or Fascicular Block

Question 4

Reversible Causes

Answer 4

Trauma (post op, blunt chest, indwelling, pulmonary catheter)
Lyme Disease
Medications (BB, CCB, Antiarrhythmic)
Toxic, Metabolic Disturbance
MI

Question 5

What workup does everyone get?

Answer 5

ECG
TSH
Troponin
Echocardiography

Question 6

Most common indication for PPM

Answer 6

Sinus Node Dysfunction
High Grade / Symptomatic AV Block

Question 7

Class I Indications for PPM in Sinus Node Dysfunction

Answer 7

Symptomatic Sinus bradycardia (HR < 40 or frequent sinus pauses)
Symptomatic Chronotropic Incompetence

Question 8

Class II Indications for PPM in Sinus Node Dysfunction

Answer 8

Sinus Bradycardia (<40) in patients suggestive of bradycardia but without a clear association between bradycardia symptoms

Sinus Node Dysfunction in a patient with unexplained syncope

Chronic HR <40 bpm while awake in minimally symptomatic patients

Question 9

Class I Indications for PPM in AV Block

Answer 9

Complete (3rd degree block) AV block with or without symptoms

Advanced 2nd degree AV block (block >/2 consecutive P waves)

2nd degree AV block, Mobitz Type II (with or without symptoms)

Symptomatic 2nd degree AV Blocck Mobitz Type I

Exercise induced 2nd or 3rd degree AV block (in abscence of Myocardial Ischemia)

Question 10

Class II Indications for PPM in AV Block

Answer 10

Primary AB block with hemodynamic compromise because of effective AV dissociation 2nd to very long PR

Bifascicular or trifascicular block associated with syncope that can be attributed to transient complete heart block