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A 72-year-old Caucasian man is brought to the emergency department (ED) after having an episode of syncope during a family meeting. His granddaughter states that in the last couple of months he has been having frequent episodes of dizziness, which are sometimes accompanied by confusion, and are not related to physical activity or changes in position. The patient lives at home, has a history of coronary artery disease and hypertension, and does not use tobacco or drink alcohol. His medications include aspirin, enalapril, metoprolol, and isosorbide mononitrate. While in the ED, his symptoms are progressively getting better. The physical examination reveals a heart rate of 45/min, a blood pressure of 90/50 mmHg, and respiratory rate of 14/min. No other important clinical findings are noticed. He is fully alert and oriented, and there are no focal neurologic findings. An EKG shows a constant PR interval of 0.18 ms and a normal QT interval, but the QRS complexes are lost on every third beat. Which of the following is the most appropriate course of action?
A) Administer intravenous atropine.
B) Observe and admit.
C) Place an external pacemaker.
D) Place a transvenous pacemaker.
E) Place the patient on telemetry or Holter monitor for 24-48 hours
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stop drugs like metoprolol and then
cccc
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2nd degree mobitz 2 ---stable----- aaatropine
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on a 2nd thought --- he is s having symptoms--- so cccc
not aaaa
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ddddddddd
This patient has Mobitz II, second-degree atrioventricular (AV) Block. In comparison to Mobitz I, second-degree AV Block (Wenckebach™s), the PR does not prolong progressively, but QRS complexes are suddenly lost. Mobitz II AV Block can cause dizziness, episodes of syncope, or transient altered mental status, thus explaining the symptoms of the patient. Because Mobitz II can progress to third-degree AV Block, it needs to be managed with a permanent pacemaker. Even if the patient is asymptomatic, the AHA/ACC (American Heart Association/American College of Cardiology) consensus advises the use of a permanent pacemaker inserted through a venous access.
(Choice B) It would be unsafe to manage a patient with this condition without a pacemaker. Observation is not an option.
(Choice A) Atropine will increase the heart rate, worsening the heart block. Atropine is usually indicated for sinus bradycardia; in that case, QRS complexes will not be lost.
(Choice C) An external pacemaker will only be a temporary solution and may require sedation of the patient. It is generally used for acute rate control, not for this chronic condition.
(Choice E) A Holter monitor or telemetry is not needed at this point to evaluate the cause of the syncope if Mobitz II is treated appropriately.
Educational Objectives:
Mobitz II second-degree AV Block is diagnosed when the EKG shows bradycardia with preservation of the PR interval, accompanied by periodic loss of QRS complexes. This condition is an indication for permanent cardiac pacemaker insertion.
