Summary
Definition
History and exam
Key diagnostic factors
- presence of risk factors
- age >50-60 years
- syncope
- heart rate <40 bpm
- pre-syncope
Other diagnostic factors
- male sex
- fatigue
- dyspnoea
- chest pain, palpitations, and nausea or vomiting
- high (less commonly, low) blood pressure
- cannon A waves
- hypoxaemia
- family history of AV block
- features of Lyme disease
Risk factors
- age-related degenerative changes in the conduction system
- increased vagal tone
- AV-nodal blocking agents
- chronic stable coronary artery disease
- acute coronary syndrome
- recent cardiac surgery, intervention, or ablation
- congestive heart failure (CHF)
- hypertension
- cardiomyopathy
- left ventricular hypertrophy
- acid-base or electrolyte disturbance
- neuromuscular disorders
- sarcoidosis
- giant cell myocarditis
- cardiac tuberculosis
- lyme disease
- infective endocarditis
- hypoxemia
- blunt cardiac injury
- some indigenous medicines
Diagnostic investigations
1st investigations to order
- 12-lead ECG
- serum troponin
- serum potassium
- serum calcium
- serum pH
- serum digitalis level
Investigations to consider
- 24-hour ambulatory monitoring or event monitoring
- chest x-ray
- transthoracic echocardiogram
- serological testing for Lyme disease
- tilt-table testing
- electrophysiological study
- cardiac stress testing
- coronary angiography
- serum CK-MB
Treatment algorithm
first-degree AV block or type I second-degree AV block
type II second-degree AV block or third-degree AV block
Contributors
Authors
Sanjiv Petkar, MD, FRCP
Consultant Cardiologist/Electrophysiologist
Royal Wolverhampton NHS Trust
Heart and Lung Centre
New Cross Hospital
Wolverhampton
UK
Disclosures
SP has received speaker's honoraria from Bayer, Bristol-Myers Squibb, MSD, and Pfizer. SP has received hospitality and/or accommodation from Bayer, Medtronic, St Jude, and Boston Scientific for attending conferences or meetings.
Dibbendhu Khanra, MD, DM Cardiology
International Clinical Fellow in Electrophysiology and Devices
Royal Wolverhampton NHS Trust
Heart and Lung Centre
New Cross Hospital
Wolverhampton
UK
Disclosures
DK declares that he has no competing interests.
Gaurav Panchal, MBBS, MRCP
Specialist Registrar in Cardiology/Electrophysiology
Royal Wolverhampton NHS Trust
Heart and Lung Centre
New Cross Hospital
Wolverhampton
UK
Disclosures
GP declares that he has no competing interests.
Acknowledgements
Dr Petkar, Dr Khanra, and Dr Panchal would like to gratefully acknowledge Dr Pathiraja, Dr Aziz, Dr Susan S. Kim, Dr John F. Beshai, and Dr Stephen L. Archer, previous contributors to this topic. JP, AA, SSK, JFB, and SLA declare that they have no competing interests.
Peer reviewers
Bradley P. Knight, MD
Professor of Medicine
Section of Cardiology
Director
Cardiac Electrophysiology
University of Chicago Medical Center
Chicago
IL
Disclosures
BPK declares that he has no competing interests.
Martin C. Burke, DO
Associate Professor of Medicine
Section of Cardiology
Cardiac Electrophysiology
University of Chicago Medical Center
Chicago
IL
Disclosures
MCB declares that he has no competing interests.
Nick Gall, MSc, MD, FRCP
Consultant Cardiologist
King’s College Hospital
London
UK
Disclosures
NG declares that he has no competing interests.
Thomas A. Dewland, MD
Associate Professor of Medicine
University of California
San Francisco
CA
Disclosures
TAD declares that he has no competing interests.
References
Key articles
Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2019 Aug 20;140(8):e382-482.Full text Abstract
Tracy CM, Epstein AE, Darbar D, et al. 2012 ACCF/AHA/HRS focused update of the 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. Heart Rhythm. 2012 Oct;9(10):1737-53.Full text Abstract
Glikson M, Nielsen JC, Kronborg MB, et al; ESC National Cardiac Societies; ESC Scientific Document Group. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J. 2021 Sep 14;42(35):3427-520.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Junctional rhythm
- Supraventricular tachycardia (SVT)
- Atrial fibrillation or multifocal atrial tachycardia (MAT)
More DifferentialsGuidelines
- 2022 AHA/ACC/HFSA guideline for the management of heart failure
- 2021 ESC guidelines on cardiac pacing and cardiac resynchronization therapy
More GuidelinesPatient information
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