CASE REPORT

August 2014

AV BLOK TOTAL
Presented By :
SYAHRIL
C 111 11 255
Supervisor :
Dr. dr. Muzzakir Amir Sp.JP(K), FIHA FICA
Department of Cardiology and Vascular
Medicine
Medical Faculty of Hasanuddin University
Makassar
2014

PATIENT IDENTITY

Name
: Mr. KM
Age
: 59 years old
Address
: Takalar
MR
: 724043
Date of Admission : 30 august 2015

HISTORY TAKING

Chief complaint: languid

Present Illness History :
Experienced since 1 week before entering

the hospital. A history of fainting there are

approximately three times before entering
the hospital. No shortness of breath, no
chest pain, palpitations nothing. A history of
consumption of drugs and herbal nothing

HISTORY TAKING

Past Illness History :

history of hypertension there is no regular

treatment
no history of diabetes mellitus
previous history of chest pain does not exist
previous history of heart disease does not
exist
high cholesterol history denied

HISTORY TAKING

Personal Life History :

No history of alcohol consumption
History of smoking since young, stopped for

the last 30 years

PHYSICAL EXAMINATION

General Status
Moderate illness / normal / Composmentis
Weight : 55 kg
Height : 165 cm
BMI

: 20,20 kg/m2

Vital Status
Blood pressure
Heart rate

:140/70 mmHg

: 36bpm

Respiratory rate : 20 rpm

Temperature

: 36,5 oC

PHYSICAL EXAMINATION

Head : anemic (-) icteric (-)

Neck : JVP R+0 cmH2O,
Lung :
Inspection
Palpation

: symmetry left=right
: mass (-), no tenderness,
normal vocal
fremity
Percussion
: sonor
Auscultation : vesicular, ronchi -/-,
wheezing -/-

PHYSICAL EXAMINATION

Cor :
Inspection : ictus cordis not visible
Palpation : ictus cordis not palpable, thrill (-)
Percussion :
Upper border 2nd ICS sinistra
Right border 4th ICS linea parasternalis dextra
Left border 5th ICS linea axillaris anterior sinistra

Auscultation : heart sound I/II pure, regular,

murmur (-)

PHYSICAL EXAMINATION

Abdomen :
Inspection : flat, follows breath movement
Auscultation : peristaltic (+), normal
Palpation : liver and spleen not palpable
Percussion : tympani

Extremities :
Edema (-)

ELECTROCARDIOGRAPHY
Sinus rhythm
irregular
Heart rate
: 36
bpm
Axis
:
normoaksis, ST
depresi V5 V6
The P wave and QRS
running separately
Conclusion :
total AV blok and
iskemik miocard
lateral

EKG after TPM (6-92015)

Sinus rhythm
rregular
Heart rate :75bpm
Axis : LAD, ST
depresi I, AFL V5 V6
The P wave and QRS
running separately
Conclusion :
total AV blok and
iskemik miocard
lateral

LABORATORY RESULTS
TEST

RESULT

NORMAL VALUE

GDS

137 mg/dL

<140

TEST

RESULT

NORMAL VALUE

SGOT

14 u/L

<38

WBC

8,9 x 103/uL

4.0 10.0 x 103

SGPT

19 u/L

<41

RBC

4,4 x 106/uL

4.0 6.0 x 106

Ureum

28

10-50

HGB

13,5 g/dL

12 16

Kreatinin

0,91

0,5-1,2

HCT

41,3%

37 48

Troponin I

0,02

<0,05

PLT

354 x 103/uL

150 400 x 103

CK

36,00

<190

PT

10,0 ctrl 11,5

10 - 14

CKMB

14,1

<25

APTT

2252 ctrl 22,5

22,0 - 30,0

Natrium

145

136 - 145

INR

0,96

Kalium

4,5

3,5 - 5,1

Klorida

110

97 - 111

Asam Urat

4,3

3,4-7,0

CHEST X-RAY

Result :
Cardiomegaly (CTI
index : 0.61) with
dilatation aorta

Echocardiograph
- Systolic and diastolic dysfunction of the left
ventricle
- Left ventricular hypertrophy konsentik
- Mild mitral regurgitation, tricuspid
regurgitation light

DIAGNOSIS

AV blok total

Hipertensi heart disease

Coronary arteri disease

TREATMENT

bed rest
O2 4 lpm via nasal cannula
0.9% NaCl IVFD 500 cc / 24 hours

Aspilet 80 mg/24 hours/oral

Clopidogrel 75 mg/24 hours/oral
Amlodipine 10 mg/ 24 hours/ oral
transcutaneus pacing

DISCUSSION

INTRODUCTION
Third-degree atrioventricular
(AV) block, also referred to as
third-degree heart block or
complete heart block, is a
disorder of the cardiac
conduction system where there
is no conduction through the
atrioventricular node (AVN).
Therefore,complete dissociation
of the atrial and ventricular
[1]The ventricular
activity exists.[1]
escape mechanism can occur
anywhere from the AVN to the
bundle-branch Purkinje system

First Degree Block

note the prolonged PR

interval

Second Degree AV Block

Mobitz type I or Winckebach

Mobitz type II

Second Degree AV Block

Type I or Wenckebach

Second Degree AV Block

Type I or Wenckebach
1.Progressive lengthening of the PR
interval from beat to beat until a
beat is dropped.
2.The PR interval after the
nonconducted P wave is shorter
than the PR interval before the
nonconducted P wave.
3.May be grouping of QRS complexes

Second Degree AV Block

Type II

Second Degree AV Block

Type II
1.Sudden appearance of a single,
non-conducted sinus P wave...
2....without...
1....the progressive prolongation
of the PR intervals
2....and the shortening of the PR
interval in the beat after the
non-conducted P wave.

Second Degree AV Block

Type II

Third-Degree (Complete) AV
Block

Third-Degree (Complete) AV
Block
1.P waves are present, with a regular
atrial rate faster than the ventricular
rate
2.QRS complexes are present, with a slow
(usually fixed) ventricular rate
3.The P wave bears no relation to the
QRS complexes, and the PR intervals
are completely variable
4.(Some properly timed P waves may be
conducted)

Third-Degree (Complete) AV
Block

QRS can be normal width or wide

etiology

AV block results from various

pathologic states causing infiltration,
fibrosis, or loss of connection in
portions of the healthy conduction
system. Third-degree AV block can be
either congenital or acquired.

continue

Drugs
Degenerative diseases Lengre disease
(sclerodegenerative process involving only the conduction
system)
Infectious causes - Lyme borreliosis (particularly in endemic
areas),Trypanosoma cruziinfection,[5]rheumatic fever,
myocarditis, Chagas disease,Aspergillusmyocarditis,
varicella-zoster virus infection,[6]valve ring abscess
Rheumatic diseases - Ankylosing spondylitis, Reiter
syndrome, relapsing polychondritis, rheumatoid arthritis,
scleroderma
Infiltrative processes - Amyloidosis, sarcoidosis, tumors,
Hodgkin disease, multiple myeloma

Neuromuscular disorders - Becker muscular

dystrophy, myotonic muscular dystrophy
Ischemic or infarctive causes - AVN block associated
with inferior wall miocardia infark(MI), His-Purkinje
block associated with anterior wall MI (see below)
Metabolic causes - Hypoxia, hyperkalemia,
hypothyroidism
Toxins Mad honey (grayanotoxin), cardiac
glycosides (eg, oleandrin), and others
Phase IV block (also known as bradycardia-related
block)
Iatrogenic causes (see below

Epidemology

In the United States, the prevalence

of third-degree AV block is 0.02%.
Worldwide, the prevalence of thirddegree AV block is 0.04%

symptoms
Occasionally, patients are asymptomatic or have
only minimal symptoms related to hypoperfusion. In
these situations, symptoms include the following:
Fatigue
Dizziness
Impaired exercise tolerance
Chest pain
Syncope
Confusion
Dyspnea
Severe chest pain
Sudden death

Work up

ECG
ECG will be found according to their degree AV
block

Chest X-ray
It can be shown an enlarged cardiac silhouette
with respect to ventricular dysfunction and
valve

electrolyte
An increase or decrease in potassium, calcium,
and magnesium can cause dysrhythmias

Treatment

Atropine (0.5 to 1 mg) can be

administered by IV bolus.
no increase isoproterenol 1 mg in
500 ml D5W with droplets for
increase the speed of the ventricular
rate
Pacemaker Implantation temporary
or permanent

prognosis

hemodynamically unstable,
syncope, hypotension, cardiovascular collapse, or
death.
Other patients can be relatively asymptomatic and
have minimal symptoms other than dizziness,
weakness, or malaise.

sudden cardiac death. The cause of death

may often be tachyarrhythmias
precipitated by the secondary changes in
ventricular repolarization (QT prolongation)
secondary to the abrupt changes in rate.

THANK YOU