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Pacemaker Dependence in Patients with Bifascicular Block During Acute Anterior Myocardial Infarction

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Pacemaker Dependence in Patients with Bifascicular Block During Acute Anterior Myocardial Infarction Br Heart J: first published as 10.1136/hrt.52.4.408 on 1 October 1984. Downloaded from Br Heart J 1984; 52: 408-12 Pacemaker dependence in patients with bifascicular block during acute anterior myocardial infarction 0 EDHAG,* L BERGFELDT,* N EDVARDSSON,t S HOLMBERG,t M ROSENQVIST,* H VALLIN* From the *Cardiac Division ofthe Deparments ofInternal Medicine, Huddinge Hospital, Karolinska Institute, Stockholm; and tSahlgren's Hospital, University ofGothenburg, Sweden SUMMARY Eleven patients with bifascicular block complicating anteroseptal acute myocardial infarc- tion were studied to determine the effect of prophylactic permanent pacing; eight of them also had transient high grade atrioventricular block during the acute phase of the infarction. One month after the infarction an electrophysiological study was performed and a bradycardia indicating pacemaker implanted. All the patients were followed for two years. Six had bradycardia detected, two of whom did not have high grade atrioventricular block during the index infarction. Seven patients died, four of them suddenly. There was no correlation between the electrophysiological findings and subse- quent development of bradycardia. Thus pacemaker dependence seems to be common in patients with bifascicular block complicating acute myocardial infarction. Mortality is, however, also high in patients treated with pacemakers. Prospective studies to determine the predictive factors in those patients with an anterior acute myocardial infarction and who benefit from a combination of permanent pacemaker treatment and antiarrhythmic treatment are needed. http://heart.bmj.com/ Patients who develop bundle branch block during the Patients and methods acute phase of an anterior myocardial infarction have a high incidence of late sudden death, which may be DEFINITIONS related to either ventricular tachycardia or the The diagnosis of acute myocardial infarction was development of high grade atrioventricular block.' In made when typical symptoms and enzyme addition, patients with bundle branch block who have abnomalities were present. The diagnosis of left bun- transient high grade atrioventricular block during the dle branch block and right bundle branch block was first days ofinfarction are considered to be subject to a based on the usual criteria.9 Left anterior fascicular on September 29, 2021 by guest. Protected copyright. high risk of sudden death after hospital discharge.2-4 block was diagnosed in the presence of a frontal plane The possible role of permanent pacemaker treat- axis deviation to the left of ::-30 and left posterior ment in preventing sudden death in this high risk fascicular block in the presence of a frontal plane axis group has been suggested.56 The purpose of this deviation to the right of : + 1200 in the absence of study was to determine whether patients who clinical evidence of right ventricular hypertrophy, developed bifascicular block during an acute anterior pulmonary hypertension, or lateral wall infarction. myocardial infarction became dependent on a Bifascicular block refers to left bundle branch block pacemaker. Pacemaker dependence was assessed or to complete right bundle branch block with either using a bradycardia indicating pacemaker.7 8 left anterior or left posterior fascicular block. High grade atrioventricular block was defined as type II second degree block or third degree block. Requests for reprints to Dr 0 Edhag, Cardiac Division, Department STUDY GROUP of Internal Medicine, Huddinge Hospital, S- 141 86 Huddinge, Eleven patients who developed bifascicular bundle Sweden. branch block during the acute phase of an anterior or Accepted for publication 10 May 1984 anteroseptal myocardial infarction were studied. 408 Br Heart J: first published as 10.1136/hrt.52.4.408 on 1 October 1984. Downloaded from Pacemaker dependence in patients with bifascicular block during acute antenior myocardial infarction 409 Table 1 Patient characteristics Case No Age (yr) Previous IHD Index infarction Treatment and sex Site Maximum serum AST activiy(pKatll) 1 75 M AMI Anteroseptal 13 2 68 M - Anteroseptal 4.8 3 64 M AMI Anteroseptal 1-4 Digoxin and frusemide 4 71 M - Anterior 2 6 Digoxin 5 73 M AMI Anterior 4-0 Digoxin and frusemide 6 73 M AMI, angina Anterior (LD increased) 7 52 M AMI, angina Anteroseptal 11-0 8 55 M - Anteroseptal 7-5 Digoxin 9 73 F Angina Anteroinferior 2 2 Digoxin 10 60 M AMI, angina Anterior 7-0 Digoxin 11 77 M Angina Anterolateral 7-9 Digoxin Median 71 4.4 AST, aspartate aminotransferase; IHD, ischaemic heart disease; AMI, acute myocardial infarction. LD, lactate dehydrogenase. Table 1 shows the clinical characteristics. The combi- beats/min the pulse generator automatically changes nation of right bundle branch block and left anterior to the higher rates (stimulation rate 70 beats/min, test fascicular block was recorded in five patients, right rate 100 beats/min), and this setting remains until the bundle branch block and left posterior fascicular generator is reprogrammed by applying an external block in one, and left bundle branch block in five. magnet. Transient high grade atrioventricular block was The occurrence of bradycardia is recognised by the recorded during the first three days after admission in pacemaker when the spontaneous heart rate falls eight patients. below 30 beats/min, and the device delivers three or more consecutive impulses or five or more impulses INTRACARDIAC ELECTROPHYSIOLOGICAL STUDY during any interval of 25 s. If an episode of bradycar- About one month after the acute infarction an elec- dia has been recognised a subsequent electrocardio- trophysiological study was performed. Either two or gram will show either a pacemaker induced rhythm three pacing electrodes with an interelectrode distance with a rate of 70 beats/min or a spontaneous heart of 1 cm were introduced percutaneously under local rhythm with a higher rate than this. In the latter situa- anaesthesia via a femoral vein and positioned high in tion the occurrence of bradycardia can be established http://heart.bmj.com/ the right atrium across the tricuspid valve and in some by applying a magnet externally. A magnet induced patients in the apex of the right ventricle. The rate of 100 beats/min indicates that an episode of intracardiac electrogram and surface leads I, II, and bradycardia has occurred, whereas a rate of 60 VI were recorded on a Minogograph recorder with beats/min shows the contrary. Further technical data frequency limits of 50-700 Hz (Siemens-Elema, Swe- on this pacemaker and the clinical results obtained den) at a paper speed of 100 mm/s. The atrioventricu- with it have been reported elsewhere.4 5 To exclude lar conduction intervals were determined as the mean intermittent undersensing or tachycardias related to of at least three beats. The intranodal conduction time bradycardia long term electrocardiography for 24- on September 29, 2021 by guest. Protected copyright. (AH) was determined from the most rapid phase of 48 h was performed after implantation of the the intrinsicoid deflection of the A wave recorded low bradycardia indicating pacemaker. in the right atrium to the first rapid phase of the H The investigation procedure was approved by the wave, and the infranodal conduction time (HV) from hospital ethical committees, and the patients gave this point to earliest ventricular activity seen in any informed consent. lead. The reference values of our laboratory for AH intervals are 55-110 ms and for HV interval 30- Results 55 ms.10 CLINICAL COURSE AND MORTALITY BRADYCARDIA INDICATING PACEMAKER After implantation of the bradycardia indicating This pulse generator was evolved from a conventional pacemaker the patients were followed for up to two ventricular inhibited lithium powered pulse generator years (Table 2). One patient had a single attack of (Siemens-Elema). Two inhibition rates, one of 70 syncope and one several short episodes of dizziness. beats/min and one of 30 beats/min, are available each These symptoms were not associated with a bradycar- with a corresponding magnet rate of 60 and 100 dia indication at subsequent follow up. One patient beats/min respectively. If there is bradycardia of <30 (case 2) had progressed to complete heart block at Br Heart J: first published as 10.1136/hrt.52.4.408 on 1 October 1984. Downloaded from 410 Edhag, Bergfeldt, Edvardsson, Holmberg, Rosenqvist, Vallin Table 2 Clinical course after implantation ofa bradycardia indicatingpacemaker, electrocardiographic data during the acute phase ofthe index infarction, and electrophsyiological data one month after infarction Case Follow up No of Bradycardia Symptoms Death AV Brundle AH HV No (month)* follow up detected block branch interval interval visits Time after Cause (degreet) blockt (ms) (ms) implantation (month) 1 1 1 Yes - 1 Reinfarction 3 RBBB, LAFB - 60 2 10d - - Heart failure 10d Heart failure 3 LBBB 90 70 3 24 10 -- - - - RBBB,LAFB 75 75 4 23 13 Yes Reinfarction - - 3 LBBB 85 75 5 6 3 Yes Pulmonary oedema- - 1 LBBB 165 90 6 15 5 Yes Syncope 15 Sudden death (AMI) - RBBB, LAFB 115 50 7 17 5 Yes Diziness 17 Sudden death 2 (type II) LBBB 70 40 8 17 11 - Syncope 20 Sudden death 3 RBBB, LAFB 75 60 (split H 9 5 3 - Heart failure 6 Reinfarction 3 RBBB, LPFB 50 45 10 5 4 - - - - 3 LBBB 65 50 11 5d - - - 5d Sudden death 3 RBBB,LAFB 45 45 (split H Median (range) 6 (0-6-24) *After electrophysiological study. tHighest recorded. AV, atrioventricular; RBBB, right bundle branch block; LBBB, left bundle branch block; LAFB, left anterior fascicular block; LPFB, left posterior fascicui block. routine follow up, and one had a reinfarction. Eight 2). Two of the patients with normal HV intervals died patients were treated for heart failure. Six had suddenly, one after a reinfarction. The elec- episodes of bradycardia detected by the pacemaker, trophysiological study thus predicted neither episodes one after 23 months (case 4). Two of the three of bradycardia or syncope during follow up nor sud- patients without high grade atrioventricular block den death.
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