BRADYCARDIA

By Aly Amer
INTRODUCTION

Bradycardia is defined as a heart rate of less than 60 beats per minute.

When you see a patient with bradycardia, important problems to think about include:
• Sinus bradycardia
• Sinoatrial node dysfunction
• Atrioventricular block (which has three levels of severity)
• Junctional and ventricular escape rhythms
• Asystole.
SINUS NODE DYSFUNCTION OVERVIEW

A disease characterized by abnormal sinus node functioning with resultant

bradycardia and cardiac insufficiency. May be multi-factorial in origin. Causes
can be considered either intrinsic or extrinsic.
Intrinsic Causes
•Idiopathic Degenerative Fibrosis (commonest).
•Ischaemia.
•Cardiomyopathies.
•Infiltrative Diseases e.g. sarcoidosis, haemochromatosis.
•Congenital abnormalities.
Extrinsic Causes
•Drugs e.g. digoxin, beta-blockers, calcium channel blockers.
•Autonomic dysfunction.
•Hypothyroidism.
•Electrolyte abnormalitites — e.g. hyperkalaemia.
ECG IN SINUS NODE DYSFUNCTION

•Sinus Bradycardia.
•Sinus Arrhythmia — associated with sinus node dysfunction in the elderly in the
absence of respiratory pattern association.
•Sinoatrial Exit Block.
•Sinus Arrest — pause > 3 seconds.
•Atrial fibrillation with slow ventricular response.
•Bradycardia – tachycardia syndrome.
• Escape rhythm (ventricular/ Junctional)
ATRIOVENTRICULAR BLOCK

• First degree atrioventricular block: the PR interval is lengthened

• Second degree atrioventricular block: some impulses from the atria are not
conducted to the ventricles. There are two sub-types:
Type I (also known as Mobitz type I or Wenckebach): the PR interval
progressively prolongs until there is a dropped QRS complex
Type II (also known as Mobitz type II): the PR interval is normal and does not
progressively lengthen. There is an intermittent loss of the QRS complex after
some P waves. There may be 2:1 or 3:1 AV block

• Third degree atrioventricular block: no impulses at all are conducted from

the atria to the ventricles.
SECOND DEGREE ATRIOVENTRICULAR BLOCK:TYPE 1
By definition, sinus rhythm means that there is one P wave before each QRS complex. There should also be
a constant PR interval at rest.
In early conduction disease, there may be a progressive prolongation of the PR interval until the delay is so
long that the atrial impulse is blocked completely and does not cross the AV node to activate the ventricles.
SECOND DEGREE ATRIOVENTRICULAR BLOCK: TYPE II
In type II second degree AV block, the PR interval is normal and does not progressively lengthen, but there
is an intermittent loss of the QRS complex after some P waves.
If alternate P waves do not produce QRS complexes, there is 2:1 AV block. If there are three P waves to
each QRS complex, there is 3:1 AV block.
THIRD DEGREE ATRIOVENTRICULAR BLOCK(CHB)
In third degree atrioventricular block, no impulses at all are conducted from the atria to the ventricles. As a
result, a lower subsidiary pacemaker initiates depolarisation of the ventricles.
The ECG shows a bradycardia of about 40 beats per minute
The ventricles depolarise independently of the atria, resulting in no consistent relationship between the P
waves and QRS complexes on the ECG
Because the lower junctional (or ventricular) pacemaker has a slower spontaneous depolarisation rate, there
are always more P waves than QRS complexes. The P waves appear to “march through” the QRS
complexes
CASES
Case 1
Case 2
Case 3
Case 4
Case 5
Case 6
Case 7
Case 8
Case 9
Case 10
 ALY AMER
THANK YOU ALY.AMER@ESNEFT.NH
S.UK