First-degree atrioventricular block

Last updated
First-degree AV block
Other namesFirst degree heart block, PR prolongation
FirstAVBlock.jpg
An ECG showing a first degree AV block of greater than 300 ms
Specialty Cardiology
Symptoms Asymptomatic
Complications Progression to second or third degree AV block
CausesFibrosis in AV node, medication, vagal tone, electrolyte disturbances
Diagnostic method Electrocardiogram
TreatmentAvoidance of AV-nodal-blocking medication

First-degree atrioventricular block (AV block) is a disease of the electrical conduction system of the heart in which electrical impulses conduct from the cardiac atria to the ventricles through the atrioventricular node (AV node) more slowly than normal. First degree AV block does not generally cause any symptoms, but may progress to more severe forms of heart block such as second- and third-degree atrioventricular block. It is diagnosed using an electrocardiogram, and is defined as a PR interval greater than 200 milliseconds. [1] First degree AV block affects 0.65-1.1% of the population with 0.13 new cases per 1000 persons each year.

Contents

Causes

The most common causes of first-degree heart block are AV nodal disease, enhanced vagal tone (for example in athletes), myocarditis, acute myocardial infarction (especially acute inferior MI), electrolyte disturbances and medication. The medications that most commonly cause first-degree heart block are those that increase the refractory time of the AV node, thereby slowing AV conduction. These include calcium channel blockers, beta-blockers, cardiac glycosides, and anything that increases cholinergic activity such as cholinesterase inhibitors. [2]

Diagnosis

In normal individuals, the AV node slows the conduction of electrical impulses through the heart. This is manifest on a surface electrocardiogram (ECG) as the PR interval. The normal PR interval is from 120 ms to 200 ms in length. This is measured from the initial deflection of the P wave to the beginning of the QRS complex. [3]

In first-degree heart block, the AV node conducts the electrical activity more slowly. This is seen as a PR interval greater than 200 ms in length on the surface ECG. It is usually an incidental finding on a routine ECG. [4]

First-degree heart block does not require any particular investigations except for electrolyte and drug screens, especially if an overdose is suspected. [5]

Treatment

The management includes identifying and correcting electrolyte imbalances and withholding any offending medications. This condition does not require admission unless there is an associated myocardial infarction. Even though it usually does not progress to higher forms of heart block, it may require outpatient follow-up and monitoring of the ECG, especially if there is a comorbid bundle branch block. If there is a need for treatment of an unrelated condition, care should be taken not to introduce any medication that may slow AV conduction. If this is not feasible, clinicians should be very cautious when introducing any drug that may slow conduction; and regular monitoring of the ECG is indicated. [6]

Prognosis

Isolated first-degree heart block has no direct clinical consequences. There are no symptoms or signs associated with it. It was originally thought of as having a benign prognosis. In the Framingham Heart Study, however, the presence of a prolonged PR interval or first degree AV block doubled the risk of developing atrial fibrillation, tripled the risk of requiring an artificial pacemaker, and was associated with a small increase in mortality. This risk was proportional to the degree of PR prolongation. [7]

A subset of individuals with the triad of first-degree heart block, right bundle branch block, and either left anterior fascicular block or left posterior fascicular block (known as trifascicular block) may be at an increased risk of progression to complete heart block. [8]

Controversy

In October 2022 the FAA quietly changed the medical policy in their Guide for Aviation Medical Examiners to define a first-degree AV block as a PR interval greater than 300ms. [9] This was considered controversial [10] in part because accepted guidelines for the PR interval remain unchanged at 200ms, [11] and in part because at the time there was no explanation of why the FAA required the change. The FAA has subsequently provided a statement explaining its reasoning. [12]

See also

Related Research Articles

<span class="mw-page-title-main">Bradycardia</span> Heart rate below the normal range

Bradycardia, also called bradyarrhythmia, is a resting heart rate under 60 beats per minute (BPM). While bradycardia can result from various pathologic processes, it is commonly a physiologic response to cardiovascular conditioning or due to asymptomatic type 1 atrioventricular block.

<span class="mw-page-title-main">Wolff–Parkinson–White syndrome</span> Abnormal heart rhythm due to faulty electrical connections in the heart

Wolff–Parkinson–White syndrome (WPWS) is a disorder due to a specific type of problem with the electrical system of the heart involving an accessory pathway able to conduct electrical current between the atria and the ventricles, thus bypassing the atrioventricular node. About 60% of people with the electrical problem developed symptoms, which may include an abnormally fast heartbeat, palpitations, shortness of breath, lightheadedness, or syncope. Rarely, cardiac arrest may occur. The most common type of irregular heartbeat that occurs is known as paroxysmal supraventricular tachycardia.

<span class="mw-page-title-main">Sinus node dysfunction</span> Medical condition

Sinus node dysfunction (SND), also known as sick sinus syndrome (SSS), is a group of abnormal heart rhythms (arrhythmias) usually caused by a malfunction of the sinus node, the heart's primary pacemaker. Tachycardia-bradycardia syndrome is a variant of sick sinus syndrome in which the arrhythmia alternates between fast and slow heart rates.

<span class="mw-page-title-main">Third-degree atrioventricular block</span> Medical condition

Third-degree atrioventricular block is a medical condition in which the electrical impulse generated in the sinoatrial node in the atrium of the heart can not propagate to the ventricles.

<span class="mw-page-title-main">Cardiac conduction system</span> Aspect of heart function

The cardiac conduction system transmits the signals generated by the sinoatrial node – the heart's pacemaker, to cause the heart muscle to contract, and pump blood through the body's circulatory system. The pacemaking signal travels through the right atrium to the atrioventricular node, along the bundle of His, and through the bundle branches to Purkinje fibers in the walls of the ventricles. The Purkinje fibers transmit the signals more rapidly to stimulate contraction of the ventricles.

<span class="mw-page-title-main">Second-degree atrioventricular block</span> Medical condition

Second-degree atrioventricular block is a disease of the electrical conduction system of the heart. It is a conduction block between the atria and ventricles. The presence of second-degree AV block is diagnosed when one or more of the atrial impulses fail to conduct to the ventricles due to impaired conduction. It is classified as a block of the AV node, falling between first-degree and third degree blocks.

<span class="mw-page-title-main">Lev's disease</span> Medical condition

Lev's disease, also known as Lenegre disease, is an idiopathic disease that can result in a complete heart block, or an extremely slowed heart rate, in patients with this condition. It is thought that for certain patients, this impairment of heart's electrical conduction system is due to fibrosis and calcification of conduction cells. This disease is considered to be age related, with increasing decline seen in elderly patients.

<span class="mw-page-title-main">Supraventricular tachycardia</span> Abnormally fast heart rhythm

Supraventricular tachycardia (SVT) is an umbrella term for fast heart rhythms arising from the upper part of the heart. This is in contrast to the other group of fast heart rhythms – ventricular tachycardia, which start within the lower chambers of the heart. There are four main types of SVT: atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia (PSVT), and Wolff–Parkinson–White syndrome. The symptoms of SVT include palpitations, feeling of faintness, sweating, shortness of breath, and/or chest pain.

<span class="mw-page-title-main">AV nodal reentrant tachycardia</span> Medical condition

AV-nodal reentrant tachycardia (AVNRT) is a type of abnormal fast heart rhythm. It is a type of supraventricular tachycardia (SVT), meaning that it originates from a location within the heart above the bundle of His. AV nodal reentrant tachycardia is the most common regular supraventricular tachycardia. It is more common in women than men. The main symptom is palpitations. Treatment may be with specific physical maneuvers, medications, or, rarely, synchronized cardioversion. Frequent attacks may require radiofrequency ablation, in which the abnormally conducting tissue in the heart is destroyed.

<span class="mw-page-title-main">Right bundle branch block</span> Heart block in the right ventricle

A right bundle branch block (RBBB) is a heart block in the right bundle branch of the electrical conduction system.

<span class="mw-page-title-main">Atrioventricular block</span> Medical condition

Atrioventricular block is a type of heart block that occurs when the electrical signal traveling from the atria, or the upper chambers of the heart, to ventricles, or the lower chambers of the heart, is impaired. Normally, the sinoatrial node produces an electrical signal to control the heart rate. The signal travels from the SA node to the ventricles through the atrioventricular node. In an AV block, this electrical signal is either delayed or completely blocked. When the signal is completely blocked, the ventricles produce their own electrical signal to control the heart rate. The heart rate produced by the ventricles is much slower than that produced by the SA node.

<span class="mw-page-title-main">Paroxysmal supraventricular tachycardia</span> Episodes of abnormally fast heart rhythm

Paroxysmal supraventricular tachycardia (PSVT) is a type of supraventricular tachycardia, named for its intermittent episodes of abrupt onset and termination. Often people have no symptoms. Otherwise symptoms may include palpitations, feeling lightheaded, sweating, shortness of breath, and chest pain.

Lown–Ganong–Levine syndrome (LGL) is a pre-excitation syndrome of the heart. Those with LGL syndrome have episodes of abnormal heart racing with a short PR interval and normal QRS complexes seen on their electrocardiogram when in a normal sinus rhythm. LGL syndrome was originally thought to be due to an abnormal electrical connection between the atria and the ventricles, but is now thought to be due to accelerated conduction through the atrioventricular node in the majority of cases. The syndrome is named after Bernard Lown, William Francis Ganong, Jr., and Samuel A. Levine.

<span class="mw-page-title-main">Multifocal atrial tachycardia</span> Fast heart rhythm associated with exacerbations of COPD

Multifocal atrial tachycardia (MAT) is an abnormal heart rhythm, specifically a type of supraventricular tachycardia, that is particularly common in older people and is associated with exacerbations of chronic obstructive pulmonary disease (COPD). Normally, the heart rate is controlled by a cluster of cells called the sinoatrial node. When a number of different clusters of cells outside the SA node take over control of the heart rate, and the rate exceeds 100 beats per minute, this is called multifocal atrial tachycardia.

<span class="mw-page-title-main">Junctional rhythm</span> Medical condition

Junctional rhythm also called nodal rhythm describes an abnormal heart rhythm resulting from impulses coming from a locus of tissue in the area of the atrioventricular node, the "junction" between atria and ventricles.

<span class="mw-page-title-main">Sinoatrial block</span> Medical condition

A sinoatrial block is a disorder in the normal rhythm of the heart, known as a heart block, that is initiated in the sinoatrial node. The initial action impulse in a heart is usually formed in the sinoatrial node and carried through the atria, down the internodal atrial pathways to the atrioventricular node (AV) node. In normal conduction, the impulse would travel across the bundle of His, down the bundle branches, and into the Purkinje fibers. This would depolarize the ventricles and cause them to contract.

A left posterior fascicular block (LPFB), also known as left posterior hemiblock (LPH), is a condition where the left posterior fascicle, which travels to the inferior and posterior portion of the left ventricle, does not conduct the electrical impulses from the atrioventricular node. The wave-front instead moves more quickly through the left anterior fascicle and right bundle branch, leading to a right axis deviation seen on the ECG.

<span class="mw-page-title-main">Junctional ectopic tachycardia</span> Irregular heartbeat due to abnormal conduction from the atrioventricular nerve

Junctional ectopic tachycardia (JET) is a rare syndrome of the heart that manifests in patients recovering from heart surgery. It is characterized by cardiac arrhythmia, or irregular beating of the heart, caused by abnormal conduction from or through the atrioventricular node. In newborns and infants up to 6 weeks old, the disease may also be referred to as His bundle tachycardia or congenital JET.

<span class="mw-page-title-main">PR interval</span> Period in electrocardiography

In electrocardiography, the PR interval is the period, measured in milliseconds, that extends from the beginning of the P wave until the beginning of the QRS complex ; it is normally between 120 and 200 ms in duration. The PR interval is sometimes termed the PQ interval.

<span class="mw-page-title-main">Arrhythmia</span> Group of medical conditions characterized by irregular heartbeat

Arrhythmias, also known as cardiac arrhythmias, are irregularities in the heartbeat, including when it is too fast or too slow. A resting heart rate that is too fast – above 100 beats per minute in adults – is called tachycardia, and a resting heart rate that is too slow – below 60 beats per minute – is called bradycardia. Some types of arrhythmias have no symptoms. Symptoms, when present, may include palpitations or feeling a pause between heartbeats. In more serious cases, there may be lightheadedness, passing out, shortness of breath, chest pain, or decreased level of consciousness. While most cases of arrhythmia are not serious, some predispose a person to complications such as stroke or heart failure. Others may result in sudden death.

References

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  3. Oldroyd, S. H.; Quintanilla Rodriguez, B. S.; Makaryus, A. N. (2023). "First Degree Heart Block". National Center for Biotechnology Information, U.S. National Library of Medicine. PMID   28846254 . Retrieved 3 July 2021.
  4. Oldroyd, S. H.; Quintanilla Rodriguez, B. S.; Makaryus, A. N. (2023). "First Degree Heart Block". National Center for Biotechnology Information, U.S. National Library of Medicine. PMID   28846254 . Retrieved 3 July 2021.
  5. Oldroyd, S. H.; Quintanilla Rodriguez, B. S.; Makaryus, A. N. (2023). "First Degree Heart Block". National Center for Biotechnology Information, U.S. National Library of Medicine. PMID   28846254 . Retrieved 3 July 2021.
  6. Oldroyd, S. H.; Quintanilla Rodriguez, B. S.; Makaryus, A. N. (2023). "First Degree Heart Block". National Center for Biotechnology Information, U.S. National Library of Medicine. PMID   28846254 . Retrieved 3 July 2021.
  7. Cheng S, Keyes MJ, Larson MG, McCabe EL, Newton-Cheh C, Levy D, Benjamin EJ, Vasan RS, Wang TJ (2009). "Long-term outcomes in individuals with prolonged PR interval or first-degree atrioventricular block". JAMA. 301 (24): 2571–2577. doi:10.1001/jama.2009.888. PMC   2765917 . PMID   19549974.
  8. "Atrioventricular Block". The Lecturio Medical Concept Library. Retrieved 3 July 2021.
  9. "Guide for Aviation Examiners, Archives and Updates" (PDF). FAA Guide for Aviation Medical Examiners. faa.gov. Archived from the original on 31 October 2022. Retrieved 31 October 2022.
  10. "The FAA has very quietly tacitly admitted that the EKGs of pilots are no longer normal". Substack. substack.com. 17 January 2023. Archived from the original on 31 March 2023. Retrieved 31 March 2023.
  11. Oldroyd, S. H.; Quintanilla Rodriguez, B. S.; Makaryus, A. N. (2023). "First Degree Heart Block". National Library of Medicine. nih.gov. PMID   28846254 . Retrieved 31 March 2023.
  12. "New FAA cardiac health rules not prompted by COVID-19 shots". Associated Press . 20 January 2023. Retrieved 12 May 2023.