8radyarrhythm|as

lrank Zlmmerman, Mu
unlverslLy of Chlcago PosplLals
D|sc|osure
no relauonshlps exlsL wlLh lndusLry
Cb[ecnves
Aher th|s course, you w||| be ab|e to exp|a|n:
Cardlac conducuon sysLem
Slnus bradycardla
Av block
8radycardla / Av block wlLh acuLe myocardlal
lnfarcuon
acemakers / lCus
Conducnon System
Slnus node
Av node
Pls/urkln[e SysLem
8undle 8ranches
Neura| and numora| kegu|anon of
Card|ac Conducnon
Vagus nerve
Slows pacemaker cells
Slows sinus node (R>L)
Slows AV node (L>R)
Minimal effect on HPS

Sympathetic nerves
Accelerates pacemaker cells
Facilitates AVN conduction
Minimal effect on HPS
afferent vagal n.
efferent vagal n.
sympathetic n.
catecholamines
Dorsal
Nucleusl



Carotid
Sinus
Sympathetic
Trunk
uesnon 1
A 64 y/o male recoverlng from CA8C surgery complalns
of dlzzlness and near-syncope whlle lylng ln bed.
1elemeLry shows Lhe followlng rhyLhm:
uesnon 1
WhaL ls Lhe mosL llkely cause of hls sympLoms?

a. CompleLe Av block
b. Slnus node dysfuncuon
c. vasovagal near-syncope
d. Second-degree Av block
"8en|gn" Causes of 8radycard|a
8locked ACs

Slnus arrhyLhmla
Slnus bradycardla wlLh [uncuonal escape
Causes of S|nus 8radycard|a
Slnus node dysfuncuon
ALhleuc hearL
Myocardlal lnfarcuon
lnferlor Ml
10-30 of pLs wlLh Ml
llbrodegenerauve changes
Surgery
Collagen vascular dlsease
lnlLrauve dlsease

vagal medlaLed
MeLabollc
Pypoxla
PypoLhermla
LlecLrolyLe abnormallues
Sepsls
MenLal depresslon
CnS (lncreased lC)
Medlcauons
Intrinsic LxLrlnslc
S|nus Node Dysfuncnon vs
Vaga|-med|ated 8radycard|a
AssoclaLed wlLh
predlsposlng facLors
(medlcauons, surgery,
age, .)
SympLoms unrelaLed Lo
slLuauon or posluon
May be assoclaLed wlLh
aLrlal arrhyLhmlas (Lachy-
brady or slck slnus
syndrome)
8elaLed Lo slLuauon
(mlcLurauon, cough,
swallowlng, curllng lron,.)
8elaLed Lo posluon (slmng
or sLandlng)
Caroud slnus
hypersensluvlLy
Slnus bradycardla may
occur ln con[uncuon wlLh
Av block
SND Vagal-mediated
1achy-8rady ("S|ck S|nus") Syndrome
AlLernaung eplsodes of Sv1 wlLh prolonged slnus
pauses aer converslon Lo slnus rhyLhm
Sv1 1ermlnaLes
Slnus pause
Sv1
Vaga|-med|ated 8radycard|a
8radycardla and Av conducuon block
8locked slnus beaL Slnus slowlng
Causes ln Lhe lCu semng:
lnLubauon, L11 sucuon, Ln1 lnLervenuons,
medlcauons, prolonged bedresL (decondluonlng)
Carond S|nus nypersens|nv|ty
SympLoms of dlzzlness/syncope wlLh Lurnlng
head or whlle wearlng ughL collars
Assess wlLh caroud slnus message (aer checklng
for brulLs): posluve LesL >3 second pause
8radycard|a 1reatment
8emove medlcauons causlng bradycardla
CorrecL meLabollc dlsLurbances
Avold Lrlggers causlng vagal-medlaLed reacuon
Medlcal lnLervenuon
1emporary or permanenL paclng
8radycard|a Med|ca| 1reatment
ALroplne
0.3mg lv every 3-3 mln (max LoLal 3 mg)
<0.3mg may lead Lo paradoxlcal bradycardla
use cauuously ln AMl:
lncreased hearL raLe may worsen lschemla/lncrease
zone of lnfarcuon
use cauuously ln hearL LransplanL:
may elLher be lneecuve (denervaLed hearL) or
paradoxlcal response (bradycardla, hearL block)
8radycard|a Med|ca| 1reatment
Lplnephrlne
2-10 mlcrograms/mln
uopamlne
2-10 mlcrograms/mln
lsoproLerenol
2-10 mlcrograms/mln
Clucagon
3mg lv followed by 3mg/hr
May be useful ln bradycardla due Lo beLa-blocker or
calclum channel blocker overdose
ACLS 8radycard|a A|gor|thm
uesnon 2
A 78 y/o male presenLs wlLh dlzzlness and syncopal eplsodes.
Pls basellne LCC shows nS8 wlLh 8888 and le fasclcular
block. Whlle belng observed on LelemeLry, Lhe followlng
rhyLhm ls recorded:
uesnon 2
WhaL ls Lhe mosL llkely cause of hls sympLoms?

a. Second-degree Lype 2 Av block
b. Slnus node dysfuncuon
c. Second-degree Lype 1 Av block
d. 1hlrd degree Av block
AV 8|ock
uenluon: An unexpecLed delay or block of an lmpulse
Lravellng from Lhe aLrlum Lo Lhe venLrlcle
Av block seen wlLh a AC or durlng aLrlal Lachycardla ls
common and may noL represenL Avn dlsease
Atrial Tachycardia with 2:1 AV conduction
2:1 Av conducuon durlng aLrlal Lachycardla
C|ass|hcanon of AV 8|ock
First Degree AV Block
Second Degree AV Block
Type 1
Second Degree AV Block
Type 2
Third Degree AV Block
S|te of AV 8|ock
First Degree AV Block
Delay in atrium or AV node leading
to prolonged PR interval
Second Degree (type 1) AV Block
Delay and block in AV node leading to
progressive increase of PR interval
Second Degree (type 2) AV Block
Intermittent block usually in the His-Purkinje
system leading to blocked P wave
Third Degree AV Block
Complete block in AV node or His-Purkinje
system
Infra-nodal conduction disease
associated with poor prognosis
and may warrant pacemaker
D|erennanng S|te of AV 8|ock
AV Node n|s-urk|n[e
C8S narrow Wlde
Wenckebach? ?es no
Lxerclse lmproves Worsens
ALroplne lmproves Worsens
Caroud Message Worsens lmproves
lsoproLerenol lmproves Worsens
uesnon 3
A 38 y/o male presenLs wlLh acuLe anLerlor myocardlal
lnfarcuon shown below:
Figure 1
uesnon 3
Pe laLer develops Lhe LCC changes shown ln
below:
Figure 2
uesnon 3
WhaL addluonal ndlng would be an lndlcauon
for placemenL of a Lemporary Lransvenous
pacemaker?

a. AsympLomauc bradycardla
b. Second degree Lype 2 Av block
c. vCs
d. Second degree Lype 1 Av block
Coronary C|rcu|anon
SA nodal arLery from
8CA (60) or LCA (40)
Av nodal arLery from
8CA (33) or LCx (43)
8lghL and le bundles
recelve blood supply
from LCA sepLal
perforaLors
8radyarrhythm|as Aher Acute Myocard|a|
Infarcnon (AMI)
Slnus bradycardla
May occur ln up Lo 30 of pLs wlLh AMl
uue Lo dlsrupuon of blood ow ln SA node arLery (60
8CA, 40 LClrcumex)
uue Lo lncreased vagal Lone ln rsL 6 hours followlng
lnferlor wall Ml

8radyarrhythm|as Aher Acute Myocard|a|
Infarcnon (AMI)
Av block
uue Lo lncreased vagal Lone ln rsL 6 hours followlng
lnferlor Ml
llrsL degree Av block
<13 lncldence, usually Av nodal
Second degree Av block
10 lncldence,
Ma[orlLy Lype 1 block (LranslenL)
1ype 2 block usually assoclaLed wlLh anLerlor Ml
1hlrd degree Av block
3-10 lncldence
May be LranslenL wlLh lnferlor Ml
noL a rlsk facLor for morLallLy s/p Ml
Management of 8radyarrhythm|as w|th
Acute Myocard|a| Infarcnon (AMI)
1reaLmenL recommended for Lhe followlng:
sympLomauc bradycardla
slnus pauses > 3 sec
P8 < 40 bpm + hypoLenslon
ALroplne 0.3-1 mg (may be eecuve ln rsL 6 hours aer
lnferlor Ml)
lf bradycardla perslsLs desplLe aLroplne, Lemporary
LranscuLaneous or Lransvenous paclng
Ind|canons for 1ransvenous 1emporary
ac|ng Aher Acute Myocard|a| Infarcnon
1. AsysLole

2. AlLernaung rlghL and le bundle branch block
3. Second degree (Lype 2) Av block wlLh new bundle
branch block
4. Second degree (Lype 2) Av block wlLh fasclcular block
and 8888
3. 1hlrd degree Av block
Card|ac acemakers
uesnon 4
A 73 y/o male ls belng LreaLed for acuLe exacerbauon
of hearL fallure. Pe has a hlsLory of pacemaker
placemenL for slnus node dysfuncuon. Pe develops
an arrhyLhmla shown ln LCC 4.
uesnon 4
uesnon 4
WhaL ls Lhe mosL approprlaLe paclng mode for Lhls
slLuauon:
a. uuu
b. AAl
c. vvl
d. ACC
NASL]8LG Gener|c acemaker Code
Common aclng Modes
vvl
used when Av conducuon ls noL lnLacL
useful for backup paclng for aLrlal arrhyLhmlas
uoes noL malnLaln Av synchrony
AAl
used for slnus node dysfuncuon and lnLacL Av conducuon
MalnLalns Av synchrony
uuu
used for rsL, second, Lhlrd degree Av block
MalnLalns Av synchrony

DDD ac|ng
D D D
Chamber aced
Chamber Sensed
Acuon or 8esponse
Lo a Sensed LvenL
A Sense ] V ace
uuu mode, lower raLe 30 bpm, upper raLe 130 bpm
SponLaneous ALrlal 8aLe = 33 ppm
Atr|a| Synchronous ac|ng
SponLaneous ALrlal 8aLe = 110 ppm
Asynchronous Modes
ACC
VCC
DCC
Magnet Mode
laclng a magneL over mosL pacemakers resulLs lf
asynchronous paclng (ACC, vCC, uCC) aL a xed
raLe (usually 83 bpm)
useful Lo sLop pacemaker medlaLed Lachycardla or Lo
prevenL lnapproprlaLe paclng lnhlbluon from
elecLrlcal nolse (eg. 8ovle durlng surgery)
laclng a magneL over mosL lCu's resulLs ln lnhlbluon
of lCu shocks buL does noL aecL paclng mode
uesnon S
A 38 y/o female wlLh a Lemporary venLrlcular
pacemaker for bradycardla followlng AMl ls found Lo
have Lhe followlng rhyLhm on LelemeLry:
uesnon S
Whlch of Lhe followlng would mosL llkely correcL Lhe
problem wlLh Lhe pacemaker?

a. uecrease senslng Lhreshold
b. lncrease paclng raLe
c. lncrease paclng energy ouLpuL
d. lncrease senslng Lhreshold
acemaker]ICD 1roub|eshoonng
undersenslng
Cversenslng
lallure Lo pace
lallure Lo capLure
undeslrable lnLeracuons
acemaker Sens|ng
2.S
1.2S
0.S
Sens|nv|ty
mVolts
Undersensing
Oversensing
Just right
Cversens|ng
T-wave oversensing
inhibits ventricular pacing
ventricular pacing at 80 ppm
Loss of Capture
noncapLure
Atr|a|
Ventr|cu|ar
noncapLure
acemaker Cutput
ulse
AmpllLude
ulse WldLh (msec)

ulse
AmpllLude
ulse WldLh (msec)

ulse
AmpllLude
ulse WldLh (msec)

l
n
c
r
e
a
s
e

A
m
p
l
l
L
u
d
e

ln
c
r
e
a
s
e

u
ls
e
w
ld
L
h

ulse AmpllLude
volLs (permanenL M)
mAmps (Lemporary M)
Dehbr|||anon 1herapy
ICD 1herapy for V1
kepeated ICD Shocks
ApproprlaLe shocks
ArrhyLhmla ls noL LermlnaLed wlLh lCu shocks
ArrhyLhmla LermlnaLed wlLh shocks buL recurs
lnapproprlaLe shocks
Lead malfuncuon resulung ln oversenslng
LMl resulung ln lnapproprlaLe shock
1 wave oversenslng (double counung)
Sv1 or slnus Lach falllng ln v1 zone
laclng a magneL over Lhe lCu wlll lnhlblL shocks!
Undes|rab|e Interacnons
18 y/o male with ICD for long QT steps
into a pool holding on to metal rail
Atrial lead
Vent lead
Noise
ICD Shock Steps out of pool