By Ahmed Adlan
03 September 2018
You receive a call from the cardiac surgeons about a patient who underwent coronary artery bypass graft surgery a few days before. The patient has a background of moderately impaired left ventricular systolic dysfunction and right bundle branch block. Electrolytes were normal and the patient was not taking any rate limiting drugs. The patient was noted to have a bradycardic episode but was asymptomatic at the time. Heart rate dropped to below 50 beats per minute for less than 20 seconds. Figure 1 shows the cardiac monitor during the bradycardia. The surgical team are concerned about heart block and would like to consider temporary pacing.
Question 1. What is the rhythm?
Question 2. What is the management?
Learning points
The ECG rhythm strip demonstrates sinus bradycardia followed by a sinus pause and junctional escape beats (Figure 2). This is indicative of sinus node dysfunction. There is no evidence of atrioventricular (AV) block. In the absence of high grade AV block and symptoms (dizziness, syncope etc.), and given the short duration (pause is less than 3 seconds) there is no clear indication for pacing (temporary or permanent) (1). The patient (and cardiac team) were reassured and the patient remained on the monitor without further events.
References
1. 2013 ESC guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J 2013; 34: 2281-2329.
03 September 2018
You receive a call from the cardiac surgeons about a patient who underwent coronary artery bypass graft surgery a few days before. The patient has a background of moderately impaired left ventricular systolic dysfunction and right bundle branch block. Electrolytes were normal and the patient was not taking any rate limiting drugs. The patient was noted to have a bradycardic episode but was asymptomatic at the time. Heart rate dropped to below 50 beats per minute for less than 20 seconds. Figure 1 shows the cardiac monitor during the bradycardia. The surgical team are concerned about heart block and would like to consider temporary pacing.
 |
| Figure 1. Cardiac monitor during bradycardia with heart rate less than 50 beats per minute. |
Question 1. What is the rhythm?
Question 2. What is the management?
Learning points
The ECG rhythm strip demonstrates sinus bradycardia followed by a sinus pause and junctional escape beats (Figure 2). This is indicative of sinus node dysfunction. There is no evidence of atrioventricular (AV) block. In the absence of high grade AV block and symptoms (dizziness, syncope etc.), and given the short duration (pause is less than 3 seconds) there is no clear indication for pacing (temporary or permanent) (1). The patient (and cardiac team) were reassured and the patient remained on the monitor without further events.
 |
| Figure 2. There are two sinus beats (arrows) followed by a brief sinus pause and a junctional escape beat (star) and a further sinus beat. In the second line there are two junctional escape beats followed by two sinus beats. The junctional beat is characterised by similar QRS morphology to the sinus beat (right bundle branch block) with evidence of a retrograde p wave (circle) seen within the QRS. |
References
1. 2013 ESC guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J 2013; 34: 2281-2329.
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