By Leslie Cho MD, Brian P. Griffin MD FACC
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Additional resources for Cardiology Intensive Board Review
In this tracing, the surface ECG shows NSR with second-degree type I AV block (Wenckebach). This pattern of block is usually localized to the AV node. However, in rare circumstances the block can occur within or below the His bundle. The wide QRS seen on the surface leads are a clue in this case that the patient has conduction disease below the level of the AV node; however, the site of block can only be determined by reviewing the His bundle recordings. In this situation, the HBE tracing shows progressive prolongation in the HV interval before it blocks in a 3:2 conduction pattern.
Antiarrhythmic drugs with use dependence, such as sotalol and dofetilide, have greater antiarrhythmic effect at slower heart rates. Consequently, drug efficacy is enhanced at the relatively slower rates in sinus rhythm, making these drugs more effective for prevention of AFib than those drugs with use dependence. Likewise, for proarrhythmia, the antiarrhythmic drugs with reverse-use dependence are more likely to produce ventricular proarrhythmia after conversion to sinus rhythm at the relatively slower sinus rate or with a postconversion pause.
B. CHB at the infra-Hisian (below the His bundle) level. In this tracing, there is NSR with CHB and a relatively wide escape rhythm. In the HBE tracing, each atrial deflection is followed by an initial His deflection and a third, smaller deflection, H', indicating that there is conduction delay within the His bundle itself. This is suggestive of significant His-Purkinje conduction disease. Therefore, the atrial impulse enters the AV node, conducts down to the His bundle (normal AH interval), where it encounters conduction delay (a “split” His made up of both an H and an H'), and then fails to propagate to the ventricle, indicating that the level of block is at or below the level of the bundle of His.