How To Manage Total Atrioventricular Block In Inferior-Posterior AMI; Is PCI More Superior Than Permanent Pacemaker?

Author : N.D Nuarisa, Y.H Oktaviono
Upload Date : 19-04-2018

Introduction: Conduction disturbances and bradyarrhythmias are well documented complications of acute myocardial infarction (AMI), which is influenced by the location of infarction. Complete heart blocks are commonly seen with inferior wall myocardial infarctions, and usually resolve in hours-to-days after revascularization. Patients with inferior or posterior AMI are more likely to develop conduction system abnormalities when compared to patients with an anterior or lateral IMA. When AV conduction block complicates AMI, the type of conduction disturbance, location of infarction, and relation of electrical disturbance to infarction must be considered if permanent pacing is contemplated.

Case Illustration: Mr. AH , 47 years old admitted for temporary pacemaker with late onset of AMI (acute myocardial infarction) to dr. Soetomo Hospital. Chief complaint dizziness and cold sweat. Risk factors : hypertension, diabetes mellitus, smoking.

Case description. Bradyarrhythmias that occur late (i.e. after 6 hours of AMI) are often require temporary pacing to improve prognosis. Symptomatic or hemodynamically important sinus bradycardia should be treated with atropine or temporary pacing if not responsive. According to Jim Man-Hong,2010 : no patient needs a PPM for 14 to 16 days after percutaneous coronary intervention (PCI). Coronary angiography showed total occlusion at LAD after D1; LCx non dominant with long lesion 70-80% at prox-distal; RCA dominant with significant stenosis 70-80% at mid and total occlusion at crux. If a TAVB is established within that time period, consideration of implanting a permanent pacemaker. AV block and persistent bundle-branch block are independently associated with worse short- and long term prognosis in both inferior/posterior & anterior/lateral MI but are more ominous in anterior/lateral MI because of a relatively greater extent of myocardial injury. 11 days after PCI in this patient, the ECG showed normal sinus rhythm with no TAVB.

Conclusion. Complete heart block after AMI occurs due to disruption of the AV node (due to ischemia and / or vagal effects) and almost always reversible overtime. Permanent pacemaker is almost never required.

KEYWORDS : inferior-posterior acute myocardial infarction, complete heart block, pacemaker.

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