HEART BLOCK

Complete Notes for Exam Preparation | Based on Sembulingam's Physiology

1. DEFINITION

What is Heart Block?

Heart block is a condition in which the conduction of the cardiac impulse from the atria to the
ventricles is delayed or completely blocked due to a defect in the atrioventricular
conduction system.

The block may occur at the level of:

→ AV Node | Bundle of His | Bundle Branches | Purkinje fibers

2. RELEVANT ANATOMY OF CONDUCTION SYSTEM

Normal Conduction Pathway

SA Node → Internodal Pathways → AV Node → Bundle of His

→ Right & Left Bundle Branches → Purkinje Fibers → Ventricular Myocardium

Normal PR Interval: 0.12 – 0.20 seconds (3–5 small squares on ECG)

Normal Heart Rate: 60–100 beats/min

AV Node Intrinsic Rate: 40–60/min (if it becomes pacemaker)

Ventricular Intrinsic Rate: 20–40/min (idioventricular rhythm)

3. CLASSIFICATION OF HEART BLOCK

Heart block is broadly classified into:

• Incomplete Heart Block – Conduction is delayed but not absent
– First Degree Heart Block
– Second Degree Heart Block (Mobitz Type I & II)
 • Complete Heart Block (Third Degree) – No conduction from atria to ventricles

4. TYPES OF HEART BLOCK — IN DETAIL

A. FIRST DEGREE HEART BLOCK

Definition
Conduction from atria to ventricles is delayed but every impulse is still conducted (no
impulse is blocked completely).

◆ ECG Features
• PR interval > 0.2 seconds (> 5 small squares) — prolonged
• All P waves are followed by QRS — 1:1 conduction ratio
• QRS complex is normal in shape and duration
• Regular rhythm

◆ Clinical Features
• Usually asymptomatic
• Detected incidentally on ECG
• No hemodynamic compromise

◆ Causes
• Rheumatic fever (most common in young)
• Increased vagal tone (athletes)
• Digitalis toxicity
• Inferior wall myocardial infarction
• Electrolyte imbalance (hyperkalemia)

◆ Treatment
• Usually no treatment required
• Treat underlying cause
• Monitor with regular ECG

B. SECOND DEGREE HEART BLOCK

In second degree heart block, some impulses are conducted and some are blocked. There are two
subtypes:
◆ Mobitz Type I — Wenckebach Phenomenon
Key Concept — Wenckebach
The PR interval progressively lengthens with each beat until finally one P wave is not
conducted (QRS is dropped). Then the cycle resets and starts again.

Analogy: Like a tired relay runner who gradually slows down until he finally drops the baton,
then a fresh runner starts again.

• PR interval: Progressive lengthening → then dropped QRS

• P:QRS ratio: > 1:1 (e.g. 4 P waves : 3 QRS = 4:3 block)
• QRS: Usually normal
• Site of block: Usually at the AV node
• Prognosis: Relatively benign
• Treatment: Atropine (if symptomatic), treat cause

◆ Mobitz Type II
Key Concept — Mobitz Type II
The PR interval is CONSTANT but occasionally a P wave is suddenly not followed by a
QRS. The block is 'all-or-nothing'.

This is more serious than Mobitz I and can suddenly progress to complete heart block.

• PR interval: Constant and fixed

• P:QRS ratio: 2:1, 3:1, 4:1 (fixed ratio — every 2nd or 3rd P wave blocked)
• QRS: Wide and bizarre (because block is in bundle branches)
• Site of block: Bundle of His or Bundle branches (infranodal)
• Prognosis: More serious — can progress to 3rd degree
• Treatment: Temporary/permanent pacemaker required

Mobitz I vs Mobitz II — Quick Comparison

Mobitz I: PR lengthens → QRS drops → reset | AV node level | Benign

Mobitz II: PR constant → sudden QRS drop | Bundle branch level | Dangerous

Memory Tip: WENCKE-BACH = PR gradually gets W-I-D-E-R until it drops

C. THIRD DEGREE HEART BLOCK (Complete Heart Block)

Definition
No impulse from the SA node reaches the ventricles. The atria and ventricles beat
completely independently — this is called AV dissociation.

A subsidiary (escape) pacemaker in the ventricles or below the block takes over ventricular
contraction.

◆ ECG Features
• P waves: Present, regular — controlled by SA node at 70–80/min
• QRS complexes: Present, regular — but at slower rate 20–40/min
• P waves and QRS have NO relationship — complete AV dissociation
• QRS: Wide and bizarre (ventricular escape rhythm)
• PR interval: Varies constantly — no fixed relationship

◆ Hemodynamics
• Ventricular rate drops to 20–40/min → Reduced cardiac output
• Blood pressure falls significantly
• Heart failure may develop
• Cerebral blood flow decreases → syncope

◆ Clinical Features
• Bradycardia (slow ventricular rate 20–40/min)
• Dizziness and syncope — Stokes-Adams attacks (see below)
• Cannon waves in JVP — atria contracting against closed tricuspid valve
• Variable intensity of S1 (because P-R relationship changes constantly)
• Heart failure symptoms — dyspnea, fatigue, peripheral edema
• Pale, cold extremities due to reduced cardiac output

◆ Escape Pacemakers in Complete Heart Block

When the AV node fails, subsidiary pacemakers take over:
• AV node / junctional: Rate 40–60/min, narrow QRS
• Bundle of His: Rate 30–50/min
• Purkinje fibers / Ventricular: Rate 20–40/min, wide bizarre QRS

5. STOKES-ADAMS SYNDROME
 Definition
Stokes-Adams syndrome (also called Stokes-Adams attack or syncope) is a sudden episode
of unconsciousness due to transient ventricular asystole or ventricular fibrillation,
seen most commonly in complete heart block.

◆ Mechanism
• In complete heart block, when the SA node impulse is completely blocked...
• ...there is a brief period of cardiac standstill (asystole) before the ventricular escape
pacemaker takes over
• During this period → no cardiac output → cerebral ischemia → sudden loss of
consciousness
• Once ventricular pacemaker resumes → blood flow restored → patient recovers

◆ Clinical Features of an Attack

• Sudden loss of consciousness — without warning
• Pallor at onset (due to sudden no cardiac output)
• Flushing on recovery (reactive hyperemia)
• Convulsions if asystole lasts > 5–10 seconds
• Pulse absent during attack
• Recovery is usually spontaneous within seconds
• Patient has no memory of the event (unlike seizures — no post-ictal confusion)

Stokes-Adams vs Epilepsy — Key Difference

Stokes-Adams: Sudden collapse, no warning, pallor then flushing, no post-ictal confusion,
tongue not bitten, ECG shows complete heart block

Epilepsy: May have aura, cyanosis (not pallor), tongue biting, urinary incontinence, post-
ictal confusion

◆ Treatment of Stokes-Adams
• Immediate: External cardiac massage if prolonged
• Temporary: IV Atropine / Isoprenaline (isoproterenol) — to increase heart rate
• Definitive: Permanent artificial pacemaker — this is the only cure

6. ECG SUMMARY TABLE

Type PR Interval P:QRS Ratio QRS Complex Key Feature

1st Degree > 0.2 sec 1:1 (all conducted) Normal Delayed conduction
(prolonged) only
2nd Degree Progressively > 1:1 (periodic Normal Wenckebach
 Type PR Interval P:QRS Ratio QRS Complex Key Feature
Mobitz I lengthens drop) phenomenon
2nd Degree Constant / Fixed > 1:1 (2:1, 3:1...) Wide & bizarre Sudden QRS drop
Mobitz II
3rd Degree No relationship Complete AV Wide & bizarre Stokes-Adams attacks
(Complete) dissociation

7. CAUSES OF HEART BLOCK

Cardiac Causes Non-Cardiac Causes Drugs

Rheumatic heart disease Hyperkalemia Digitalis toxicity
Myocardial infarction (inf. wall) Hypothyroidism Beta-blockers
Lev's disease (fibrosis) Lyme disease Calcium channel blockers
Lenègre's disease Sarcoidosis Amiodarone
Congenital heart block SLE / Connective tissue Quinidine
disease

8. TREATMENT SUMMARY

Treatment by Type
1st Degree: No specific treatment. Treat underlying cause. Regular monitoring.

2nd Degree Mobitz I: Atropine if symptomatic. Usually benign. Treat cause.

2nd Degree Mobitz II: Pacemaker implantation — temporary or permanent.

3rd Degree (Complete): Permanent artificial pacemaker is the definitive treatment.

Stokes-Adams attack (acute): CPR → IV Atropine → IV Isoprenaline → Temporary

transvenous pacing → Permanent pacemaker

Artificial Pacemaker
• Delivers electrical impulses to stimulate ventricular contraction
 • Pacing rate: 70–80/min (physiological)
• Temporary pacemaker: Via transvenous route through jugular/subclavian vein
• Permanent pacemaker: Surgically implanted, battery-powered
• Modern pacemakers are demand pacemakers — only fire when native rate drops below set
rate

9. QUICK REVISION — EXAM HIGH YIELD POINTS

Must Know for Exams

✓ Normal PR interval = 0.12 – 0.20 sec

✓ 1st degree = PR prolonged > 0.2 sec, all P waves conducted

✓ Wenckebach = PR progressively lengthens → QRS dropped → cycle resets

✓ Mobitz II = PR constant → sudden dropped QRS (more dangerous)

✓ Complete (3rd degree) = AV dissociation, ventricular rate 20–40/min

✓ Stokes-Adams = sudden syncope due to ventricular asystole in complete HB

✓ Pallor at onset + Flushing on recovery = hallmark of Stokes-Adams

✓ Definitive treatment of complete heart block = PERMANENT PACEMAKER

✓ Idioventricular rate = 20–40/min (escape pacemaker in ventricles)

✓ Cannon waves in JVP = seen in complete heart block

Memory Tricks
PR prolonged = 1st degree (just Prolonged, no drop)

Wencke-BACH = progressive then Bach/BLOCK

Mobitz II = More serious (both start with M)

Complete = Complete dissociation = Complete CHAOS between P and QRS

Stokes-Adams = Starts suddenly, Stops suddenly

Good luck in your exam! You've got this! ✓