Conduction abnormalities after myocardial infarction
- Peter J Zimetbaum, MD
Peter J Zimetbaum, MD
- Section Editor — Cardiac Arrhythmias
- Associate Professor of Medicine
- Harvard Medical School
- Mark E Josephson, MD
Mark E Josephson, MD
- Professor of Medicine
- Harvard Medical School
- Section Editors
- Bradley P Knight, MD, FACC
Bradley P Knight, MD, FACC
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Feinberg School of Medicine, Northwestern University
- Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Coronary Heart Disease
- Section Editor — Myopericardial Disease
- Professor of Medicine
- Mayo Medical School
- James Hoekstra, MD
James Hoekstra, MD
- Section Editor — Adult Cardiology Emergencies
- Professor and Fredrick Glass Chair
- Wake Forest University
Bradyarrhythmias and conduction disturbances are well-recognized complications of acute myocardial infarction (MI). They are induced by either autonomic imbalance or ischemia and necrosis of the conduction system. It is important to recognize which bradyarrhythmias are transient and which are likely to progress to irreversible and symptomatic high-degree block.
The major conduction abnormalities associated with acute MI will be reviewed here; tachyarrhythmias, the other major dysrhythmic complication of MI, are discussed separately. (See "Supraventricular arrhythmias after myocardial infarction" and "Clinical features and treatment of ventricular arrhythmias during acute myocardial infarction".)
Issues related to LBBB — There are two specific issues related to left bundle branch block (LBBB) in association with an acute MI:
●LBBB can complicate the electrocardiographic diagnosis of MI. (See "Electrocardiographic diagnosis of myocardial infarction in the presence of bundle branch block or a paced rhythm".)
●Patients with a new or presumably new LBBB are treated as if they have an ST elevation MI . (See "Overview of the acute management of ST elevation myocardial infarction".)
- Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction. www.acc.org/qualityandscience/clinical/statements.htm (Accessed on August 24, 2006).
- Harpaz D, Behar S, Gottlieb S, et al. Complete atrioventricular block complicating acute myocardial infarction in the thrombolytic era. SPRINT Study Group and the Israeli Thrombolytic Survey Group. Secondary Prevention Reinfarction Israeli Nifedipine Trial. J Am Coll Cardiol 1999; 34:1721.
- Wong CK, Stewart RA, Gao W, et al. Prognostic differences between different types of bundle branch block during the early phase of acute myocardial infarction: insights from the Hirulog and Early Reperfusion or Occlusion (HERO)-2 trial. Eur Heart J 2006; 27:21.
- Rosenbaum M, Elizari MV, Lazzari JO. The Hemiblocks. Tampa Tracings, Tampa, 1970.
- Uhley HN. Some controversy regarding the peripheral distribution of the conduction system. Am J Cardiol 1972; 30:919.
- Hecht HH, Kossmann CE, Childers RW, et al. Atrioventricular and intraventricular conduction. Revised nomenclature and concepts. Am J Cardiol 1973; 31:232.
- Demoulin JC, Kulbertus HE. Histopathological examination of concept of left hemiblock. Br Heart J 1972; 34:807.
- Zimetbaum PJ, Josephson ME. Use of the electrocardiogram in acute myocardial infarction. N Engl J Med 2003; 348:933.
- Godman MJ, Lassers BW, Julian DG. Complete bundle-branch block complicating acute myocardial infarction. N Engl J Med 1970; 282:237.
- Gupta PK, Lichstein E, Chadda KD. Heart block complicating acute inferior wall myocardial infarction. Chest 1976; 69:599.
- Sugiura T, Iwasaka T, Hasegawa T, et al. Factors associated with persistent and transient fascicular blocks in anterior wall acute myocardial infarction. Am J Cardiol 1989; 63:784.
- Goldberg RJ, Zevallos JC, Yarzebski J, et al. Prognosis of acute myocardial infarction complicated by complete heart block (the Worcester Heart Attack Study). Am J Cardiol 1992; 69:1135.
- Hindman MC, Wagner GS, JaRo M, et al. The clinical significance of bundle branch block complicating acute myocardial infarction. 1. Clinical characteristics, hospital mortality, and one-year follow-up. Circulation 1978; 58:679.
- Hindman MC, Wagner GS, JaRo M, et al. The clinical significance of bundle branch block complicating acute myocardial infarction. 2. Indications for temporary and permanent pacemaker insertion. Circulation 1978; 58:689.
- Scheinman MM, Gonzalez RP. Fascicular block and acute myocardial infarction. JAMA 1980; 244:2646.
- Dubois C, Piérard LA, Smeets JP, et al. Short- and long-term prognostic importance of complete bundle-branch block complicating acute myocardial infarction. Clin Cardiol 1988; 11:292.
- Go AS, Barron HV, Rundle AC, et al. Bundle-branch block and in-hospital mortality in acute myocardial infarction. National Registry of Myocardial Infarction 2 Investigators. Ann Intern Med 1998; 129:690.
- Stenestrand U, Tabrizi F, Lindbäck J, et al. Comorbidity and myocardial dysfunction are the main explanations for the higher 1-year mortality in acute myocardial infarction with left bundle-branch block. Circulation 2004; 110:1896.
- Lamas GA, Muller JE, Turi ZG, et al. A simplified method to predict occurrence of complete heart block during acute myocardial infarction. Am J Cardiol 1986; 57:1213.
- Meine TJ, Al-Khatib SM, Alexander JH, et al. Incidence, predictors, and outcomes of high-degree atrioventricular block complicating acute myocardial infarction treated with thrombolytic therapy. Am Heart J 2005; 149:670.
- GISSI-2: a factorial randomised trial of alteplase versus streptokinase and heparin versus no heparin among 12,490 patients with acute myocardial infarction. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico. Lancet 1990; 336:65.
- Grines CL, Browne KF, Marco J, et al. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. The Primary Angioplasty in Myocardial Infarction Study Group. N Engl J Med 1993; 328:673.
- An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. The GUSTO investigators. N Engl J Med 1993; 329:673.
- Archbold RA, Sayer JW, Ray S, et al. Frequency and prognostic implications of conduction defects in acute myocardial infarction since the introduction of thrombolytic therapy. Eur Heart J 1998; 19:893.
- Newby KH, Pisanó E, Krucoff MW, et al. Incidence and clinical relevance of the occurrence of bundle-branch block in patients treated with thrombolytic therapy. Circulation 1996; 94:2424.
- Aplin M, Engstrøm T, Vejlstrup NG, et al. Prognostic importance of complete atrioventricular block complicating acute myocardial infarction. Am J Cardiol 2003; 92:853.
- Haim M, Hod H, Kaplinsky E, et al. Frequency and prognostic significance of high-degree atrioventricular block in patients with a first non-Q-wave acute myocardial infarction. The SPRINT Study Group. Second Prevention Reinfarction Israeli Nifedipine Trial. Am J Cardiol 1997; 79:674.
- Rathore SS, Gersh BJ, Berger PB, et al. Acute myocardial infarction complicated by heart block in the elderly: prevalence and outcomes. Am Heart J 2001; 141:47.
- Feigl D, Ashkenazy J, Kishon Y. Early and late atrioventricular block in acute inferior myocardial infarction. J Am Coll Cardiol 1984; 4:35.
- Berger PB, Ruocco NA Jr, Ryan TJ, et al. Incidence and prognostic implications of heart block complicating inferior myocardial infarction treated with thrombolytic therapy: results from TIMI II. J Am Coll Cardiol 1992; 20:533.
- Berger PB, Ryan TJ. Inferior myocardial infarction. High-risk subgroups. Circulation 1990; 81:401.
- Nicod P, Gilpin E, Dittrich H, et al. Long-term outcome in patients with inferior myocardial infarction and complete atrioventricular block. J Am Coll Cardiol 1988; 12:589.
- Behar S, Zissman E, Zion M, et al. Complete atrioventricular block complicating inferior acute wall myocardial infarction: short- and long-term prognosis. Am Heart J 1993; 125:1622.
- Clemmensen P, Bates ER, Califf RM, et al. Complete atrioventricular block complicating inferior wall acute myocardial infarction treated with reperfusion therapy. TAMI Study Group. Am J Cardiol 1991; 67:225.
- Abidov A, Kaluski E, Hod H, et al. Influence of conduction disturbances on clinical outcome in patients with acute myocardial infarction receiving thrombolysis (results from the ARGAMI-2 study). Am J Cardiol 2004; 93:76.
- Sgarbossa EB, Pinski SL, Topol EJ, et al. Acute myocardial infarction and complete bundle branch block at hospital admission: clinical characteristics and outcome in the thrombolytic era. GUSTO-I Investigators. Global Utilization of Streptokinase and t-PA [tissue-type plasminogen activator] for Occluded Coronary Arteries. J Am Coll Cardiol 1998; 31:105.
- Guerrero M, Harjai K, Stone GW, et al. Comparison of the prognostic effect of left versus right versus no bundle branch block on presenting electrocardiogram in acute myocardial infarction patients treated with primary angioplasty in the primary angioplasty in myocardial infarction trials. Am J Cardiol 2005; 96:482.
- Ricou F, Nicod P, Gilpin E, et al. Influence of right bundle branch block on short- and long-term survival after acute anterior myocardial infarction. J Am Coll Cardiol 1991; 17:858.
- Brilakis ES, Wright RS, Kopecky SL, et al. Bundle branch block as a predictor of long-term survival after acute myocardial infarction. Am J Cardiol 2001; 88:205.
- Rathore SS, Weinfurt KP, Gersh BJ, et al. Treatment of patients with myocardial infarction who present with a paced rhythm. Ann Intern Med 2001; 134:644.
- Wong CK, French JK, Aylward PE, et al. Patients with prolonged ischemic chest pain and presumed-new left bundle branch block have heterogeneous outcomes depending on the presence of ST-segment changes. J Am Coll Cardiol 2005; 46:29.
- Al-Faleh H, Fu Y, Wagner G, et al. Unraveling the spectrum of left bundle branch block in acute myocardial infarction: insights from the Assessment of the Safety and Efficacy of a New Thrombolytic (ASSENT 2 and 3) trials. Am Heart J 2006; 151:10.
- Zimetbaum PJ, Buxton AE, Batsford W, et al. Electrocardiographic predictors of arrhythmic death and total mortality in the multicenter unsustained tachycardia trial. Circulation 2004; 110:766.
- Freedman RA, Alderman EL, Sheffield LT, et al. Bundle branch block in patients with chronic coronary artery disease: angiographic correlates and prognostic significance. J Am Coll Cardiol 1987; 10:73.
- Cooper MJ, Abinader EG. Atropine-induced ventricular fibrillation: case report and review of the literature. Am Heart J 1979; 97:225.
- Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation 2008; 117:e350.
- www.acc.org/qualityandscience/clinical/statements.htm (Accessed on September 18, 2007). www.acc.org/qualityandscience/clinical/statements.htm (Accessed on September 18, 2007).
- Issues related to LBBB
- Limitations of incidence and prognosis data
- ANATOMY AND BLOOD SUPPLY OF THE CONDUCTION SYSTEM
- Blood supply
- FREQUENCY OF HIGH-DEGREE BLOCK WITH ACUTE MI
- Multicenter retrospective reviews
- MILIS trial
- Thrombolysis trials
- Non-ST elevation MI
- CONDUCTION DISTURBANCES AND INFARCT LOCATION
- Inferior MI
- Anterior MI
- MORTALITY AND HEART BLOCKS
- High degree AV block
- Bundle branch block
- - Increased comorbidities
- - New versus chronic BBB
- - ST segment changes
- - Distant prior MI
- MANAGEMENT OF HEART BLOCK
- Use of atropine
- Use of cardiac pacing
- Indications for temporary transvenous pacing
- - Standard indications
- - Special circumstances
- Indications for permanent pacing
- - Implantable cardioverter-defibrillator
- - Cardiac resynchronization therapy
- - AV synchrony
- - Managed ventricular pacing