Bradyarrhythmia Made

Simple

Ignatius Yansen Ng, MD, FIHA FAsCC

 Ignatius Yansen Ng, MD, FIHA
Education
2017 Intervention Cardiology Fellow at Gatot Subroto Military Hospital, Jakarta and Sardjito
General Hospital, Jogjakarta (Intervention Cardiologist)
2014-2015 Electrophysiology Fellow at National Center for Cardiovascular Disease, Fuwai
Hospital, Beijing, China (Electrophysiologist)
2008-2013 Department of Cardiology and Vascular Medicine Faculty of Medicine University of
Indonesia/ National Cardiac Center Harapan Kita Hospital, Jakarta (cardiologist)
1998-2004 Faculty of Medicine University of Indonesia/ Cipto Mangunkusumo General Hospital
(medical doctor) @ignatiusyansen
Working Experiences
2020- now Intervention Cardiologist/Electrophysiologist at EKA Hospital, Banten
2015- now Intervention Cardiologist/ Electrophysiologist at Tangerang General Hospital, Banten
2015- 2020. Intervention Cardiologist/ Electrophysiologist at Mitra Keluarga Kelapa Gading, Jakarta
2013-2014 Cardiologist at Tarakan General Hospital, North Kalimantan
2013-2014 Visiting Lecturer at Borneo University, Tarakan, North Kalimantan
2008-2013 Cardiology trainee at National Cardiac Center Harapan Kita Hospital
2007 Medical doctor at Medicins Sans Frontiers (MSF) Belgium ( NGO ) in Sugapa and
Timika, Papua (meningitis breakout)
2007 Medical doctor at Medicins Sans Frontiers (MSF) Belgium ( NGO ) in Padang and
Mentawai (earthquake)
2005-2007 Head of Community Health Center at Atsj , Asmat, Papua
 ARRHYTHMIA
- Arrhythmia: when your heart doesn’t beat normally.
- Your heart beats too fast, too slow or irregular.
ARRHYTHMIA??
• Normal (60-100)

• Tachycardia (>100)

• Bradikardia (<60)

• Irregular
NORMAL ECG
Patient's complain ??
mild-severe

• Palpitation
• Dizzines
• Chest pain
• Syncope
• Dyspnea
• Fatique
 Diagnostic Tool for Arrhythmia
• ECG
• 24h Holter monitor
• ILR (Implantable loop recorder)
• Echocardiogram
• CT scan/ MRI
• Stress test
• Tilt Table Test
• Coronary angiography
• Electrophysiology study
Electrocardiography
70 Years old Lady fainting
Implantable Loop Recorder
Echocardiography
Treadmill Test
TILT TABLE TEST
Coronary Angiography
Electrophysiology Study
Bradyarrhythmias
•Sinus bradycardia
•Sinus arrest (“Sick Sinus Syndrome”)
•Atrioventricular block
• First degree
• Second degree
- type I (Wenckebach) / type II
• Third degree
Cardiac Activity Related to ECG

19
AV Synchrony
Classifications of Bradyarrhythmias
There are two types of bradyarrhythmias

• Those related to problems with impulse formation

Sinus node

AV node

• Those related to problems with impulse conduction

SA Exit Block
SA Exit Block
Sinus Arrest
First Degree AV Block
First Degree AV Block
Second Degree Type 1
Second Degree type 2
Total AV Block
Fascicular Block
Left Anterior Fascicular Block (LAFB)
Left Posterior Fascicular Block (LPFB)
2018 ACC/AHA/HRS Guideline on the
Evaluation and Management of Patients With
Bradycardia and Cardiac Conduction Delay

Developed in Collaboration With and Endorsed by the American

Association for Thoracic Surgery, the Pediatric & Congenital
Electrophysiology Society, and the Society of Thoracic Surgeons

© American College of Cardiology Foundation and American Heart Association

Chronic SND Management Algorithm
Sinus node dysfunction

Confirm symptoms
Rule out reversible
causes
Due
to required GDMT
(no reasonable
alternative)
Symptoms
No correlate with
bradycardia
Yes

Yes No (or asymptomatic)

Likely/uncertain
Observation

Permanent pacing Oral theophylline Permanent pacing

(Class I) (Class IIb) (Class III: Harm)

Response
Infrequent
suggests symptomatic
pacing? Significant
sinus node
comorbidities?
dysfunction?
No
Yes No
Yes

Single chamber
Willing to
ventricular pacing
have a PPM?
(Class IIa)
Normal
AV conduction Yes No
and reason to
avoid an RV Oral theophylline
lead? (Class IIb)

Yes No

Single chamber Dual chamber pacing

atrial pacing (Class I)
(Class I)
Program to minimize
ventricular pacing
(Class IIa)
 Management of Bradycardia or Pauses Attributable to Chronic
Atrioventricular Block Algorithm
AV Block

Marked first Mobitz Type I Complete Heart

degree AV Block block Block (acquired),
Advanced AV
Block,
Symptoms* Symptoms* Mobitz Type II,
Evidence for
Yes No Infranodal Block
Yes No

Lamin A/C, Neuromuscular

Neuromuscular disease associated with
disease progressive conduction tissue
disorder
Yes No

Neuromuscular Lamin Yes No

No Observation
disease‡ A/C†
Observation
Yes Yes

Permanent Permanent
Permanent Permanent Permanent Permanent Permanent Permanent
pacing pacing
pacing pacing pacing pacing pacing pacing
(Class III: (Class III:
(Class IIa) (Class IIb) (Class IIa) (Class IIa) (Class I) (Class I)
Harm) Harm)

Consider risk of ventricular arrhythmia

(Class I)

Cardiac
resynchronization therapy
Management of Conduction Disorders Algorithm
Conduction disorder:
BBB or fascicular block with
1:1 AV conduction*

Syncope,
BBB, and
HV >70ms
Permanent pacing
Yes
(Class I)
No

Alternating
BBB
Permanent pacing
Yes
No (Class I)

LVEF 36-50%, LBBB,

QRS >150 ms, and Class II or
greater HF symptoms

Cardiac resynchronization
Yes therapy
No
(Class IIb)

Symptoms
suggest intermittent
AV block?

Yes No

AV block diagnostic
Observation
algorithm†
Medications That Can Induce/Exacerbate Bradycardia
or Conduction Disorders
Antihypertensive Antiarrhythmic Psychoactive Other
• Beta-adrenergic receptor • Adenosine • Donepezil • Anesthetic drugs
blockers (including beta- • Amiodarone • Lithium (propofol)
adrenergic blocking eye • Dronedarone • Opioid analgesics • Cannabis
drops used for • Flecainide • Phenothiazine • Digoxin
glaucoma) • Procainamide antiemetics and • Ivabradine
• Clonidine • Propafenone antipsychotics • Muscle relaxants
• Methyldopa • Quinidine • Phenytoin (e.g.,
• Non-dihydropyridine • Sotalol • Selective serotonin succinylcholine)
calcium channel blockers reuptake inhibitors
• Reserpine • Tricyclic
antidepressants
Common Potentially Reversible/Treatable Causes of SND
Acute myocardial ischemia or infarction

Athletic training

Atrial fibrillation

Cardiac surgery
• Valve replacement, maze procedure, coronary artery bypass graft

Drugs or toxins*
• Toluene, organophosphates, tetrodotoxin, cocaine

Electrolyte abnormality
• Hyperkalemia, hypokalemia, hypoglycemia

Heart transplant : Acute rejection, chronic rejection, remodeling

Hypervagotonia

Hypothermia
• Therapeutic (post-cardiac arrest cooling) or environmental exposure

Hypothyroidism

Hypovolemic shock

Hypoxemia, hypercarbia, acidosis

• Sleep apnea, respiratory insufficiency (suffocation, drowning, stroke, drug overdose)

Infection
• Lyme disease, legionella, psittacosis, typhoid fever, typhus, listeria, malaria, leptospirosis, Dengue fever, viral hemorrhagic fevers,
Guillain-Barre

Medications*
• Beta blockers, non-dihydropyridine calcium channel blockers, digoxin, antiarrhythmic drugs, lithium, methyldopa, risperidone, cisplatin,
interferon
So when we implant pacemaker??

SYMPTOMATIC BRADICARDIA
71 years old with syncope..
What should be done?
71 years old male comes with frequent syncope
HOLTER

BRADI TACHY SYNDROME

AF SLOW RESPONSE
HOLTER

SINUS NODE DYSFUNCTION

JUNCTIONAL RHYTHM
TOTAL AV BLOCK
 CONCLUSION
• Bradyarrhythmia is when the heart rate slower than normal
• Symptoms vary from asymptomatic to severe
• Involve cardiac pacemaker (SA node) or conduction system
• First role out reversible causes
• There is no lower limit of heart rate for treatment
• Therapy: permanent pacemaker for symptomatic bradicardia
@ignatiusyansen