Emergency Department ECG
Right Side ECG
- Patient arrived bradycardic and hypotension
- Complete AV block on ECG
- Transcutaneous pacing started while awaiting cath
- Patient converted to sinus tach while transvenous pacer being placed
Cardiac Cath Report
1. LMCA: Large, long, widely patent, gives rise to the LAD and LCX.
2. LAD: Normal caliber, transapical, mid LAD 40%, small D1, D2, D3 are patent.
3. LCX: Normal caliber, nondominant, OMB1 is normal caliber and patent, small AV groove LCX is patent.
4. RCA: Large, dominant, mid 95% high grade stenosis with thrombus, patent right PDA and right PL branches.
Complete Heart Block
- Complete absence of AV conduction
- Perfusing rhythm is maintained by a junctional or ventricular escape rhythm
- It may be due to progressive fatigue of AV nodal cells as per Mobitz I (e.g. secondary to increased vagal tone in the acute phase of an inferior MI).
- Alternatively, it may be due to sudden onset of complete conduction failure throughout the His-Purkinje system, as per Mobitz II (e.g. secondary to septal infarction in acute anterior MI).
- Inferior MI
- AV nodal blocking drugs
- Idiopathic degeneration of conduction system
- Complete Heart Block Complicating ST-Segment Elevation Myocardial Infarction : Temporal Trends and Association With In-Hospital Outcomes [JACC 2015;1(6):529-38]
- 2,273,853 patients with STEMI, 49,882 (2.2%) had CHB
- STEMI patients with CHB had higher in-hospital mortality than those without CHB
- The higher mortality associated with CHB was independent of the location of STEMI
- The incidence of CHB was higher in patients with inferior STEMI compared with those with anterior STEMI
- 40-50% of all myocardial infarctions.
- more favorable prognosis than anterior myocardial infarction
- Up to 40% of patients with an inferior STEMI will have a concomitant right ventricular infarction. These patients may develop severe hypotension in response to nitrates and generally have a worse prognosis.
- Confirmed with Right sided ECG, Elevation in V4R
- Up to 20% of patients with inferior STEMI will develop significant bradycardia due to second- or third-degree AV block. These patients have an increased in-hospital mortality (>20%).
- ECG findings
- ST elevation in leads II, III and aVF
- Reciprocal ST depression in aVL (± lead I)
- RCA (80%): Elevation in III > II, Reciprocal depression in I
- LCx (20%): Elevation in III = II, No reciprocal depression in I