Conduction abnormalities after myocardial infarction
- Peter J Zimetbaum, MD
Peter J Zimetbaum, MD
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Harvard Medical School
- Joseph E Marine, MD, FACC, FHRS
Joseph E Marine, MD, FACC, FHRS
- Associate Professor of Medicine
- Associate Director of Electrophysiology
- Johns Hopkins University School of Medicine
- 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; Myopericardial Disease
- Professor of Medicine
- Mayo Clinic College of Medicine
- James Hoekstra, MD
James Hoekstra, MD
- Section Editor — Adult Cardiology Emergencies
- Professor and Fredrick Glass Chair
- Wake Forest University
Electrical conduction abnormalities are well-recognized complications of acute myocardial infarction (MI). They are caused by either autonomic imbalance or ischemia and necrosis of the conduction system. The most common clinical consequence is bradycardia, which may or may not be symptomatic. Complete heart block with a slow escape rhythm is a potentially fatal event in this setting if not detected and treated. In addition, it is important to recognize which bradyarrhythmias are transient and which are likely to progress to irreversible and symptomatic high-degree atrioventricular block.
The major conduction abnormalities associated with acute MI will be reviewed here. Supraventricular arrhythmias, including sinus bradycardia, are discussed separately. (See "Supraventricular arrhythmias after myocardial infarction" and "Clinical features and treatment of ventricular arrhythmias during acute myocardial infarction".)
ANATOMY AND BLOOD SUPPLY OF THE CONDUCTION SYSTEM
After leaving the atrioventricular (AV) node, the bundle of His divides at the juncture of the fibrous and muscular boundaries of the interventricular septum into the right and left bundle branches (figure 1). The right bundle branch courses down the right side of interventricular septum near the endocardium in its upper third, deeper in the muscular portion of the septum in the middle third, and then again near the endocardium in its lower third. The right bundle does not branch throughout most of its course, but it begins to ramify as it approaches the base of the right anterior papillary muscle with fascicles going to the septal and free wall of the right ventricle. The apical free wall at the base of the right anterior papillary muscle is the earliest site of right ventricular activation.
The left bundle branch penetrates the membranous portion of the interventricular septum under the aortic ring. Shortly thereafter, it divides into several discrete branches [1-4]:
●An anterior fascicle that crosses the left ventricular outflow tract and terminates in the Purkinje system of the anterolateral wall of the left ventricle.
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- ANATOMY AND BLOOD SUPPLY OF THE CONDUCTION SYSTEM
- TYPES OF CONDUCTION ABNORMALITIES
- CONDUCTION DISTURBANCES BASED ON INFARCT LOCATION
- Inferior MI
- Anterior MI
- High degree AV block
- Bundle branch block
- - New versus chronic BBB
- MANAGEMENT OF AV BLOCK
- Temporary transvenous pacing
- Indications for permanent pacing
- SUMMARY AND RECOMMENDATIONS