Heart block

Heart block (HB)[1] is a disorder in the heart's rhythm due to a fault in the
Heart block
natural pacemaker.[2] This is caused by an obstruction - a block - in the electrical
conduction system of the heart. Sometimes a disorder can be inherited. Despite Specialty Cardiology
the severe-sounding name, heart block may cause no symptoms at all in some
cases, or occasional missed heartbeats in other cases (which can cause light-headedness, syncope (fainting), and palpitations), or
may require the implantation of an artificial pacemaker, depending upon exactly where in the heart conduction is being impaired
and how significantly it is affected.

Heart block should not be confused with other conditions, which may or may not be co-occurring, relating to the heart and/or
other nearby organs that are or can be serious, including angina (heart-related chest pain), heart attack (myocardial infarction),
any type of heart failure, cardiogenic shock or other types of shock, different types of abnormal heart rhythms (arrhythmias),
cardiac arrest, or respiratory arrest.

In severe cases where the heart's ability to control and trigger heartbeats may be completely ineffective or unreliable, heart block
can usually be treated by inserting an artificial pacemaker, a medical device that provides correct electrical impulses to trigger
heart beats, compensating for the natural pacemaker's unreliability. Therefore, heart block frequently has no effects, or mild and
occasional effects, and is not life-threatening in the vast majority of cases, and is usually treatable in more serious cases.

The human heart uses electrical signals to maintain and initiate the regular heartbeat in a living person; incorrect conduction or
interference from external sources can lead to mild or serious symptoms depending upon the location of the blockage and how
severely conduction is being blocked. Conduction is initiated by the sinoatrial node ("sinus node" or "SA node"), and then travels
to the atrioventricular node ("AV node") which also contains a secondary "pacemaker" that acts as a backup for the SA nodes,
then to the bundle of His and then via the bundle branches to the point of the apex of the fascicular branches. Blockages are
therefore classified based on where the blockage occurs - namely the SA node ("Sinoatrial block"), AV node ("AV block" or
AVB), and at or below the bundle of His ("Intra-Hisian" or "Infra-Hisian block" respectively). Infra-Hisian blocks may occur at
the left or right bundle branches ("bundle branch block") or the fascicles of the left bundle branch ("fascicular block" or
"Hemiblock"). SA and AV node blocks are each divided into three degrees, with second-degree blocks being divided into two
types (written either "type I or II" or "type 1 or 2"). The term "Wenckebach block" is also used for second degree type 1 blocks of
either the SA or AV node; in addition second-degree blocks type 1 and 2 are also sometimes known as " Mobitz 1" and "Mobitz
2".

Clinically speaking, the blocks tend to have more serious potential the closer they are to the "end" of the electrical path (the
muscles of the heart regulated by the heartbeat), and less serious effects the closer they are to the "start" (at the SA node), because
the potential disruption becomes greater as more of the "path" is "blocked" from its "end" point. Therefore, most of the important
heart blocks are AV nodal blocks and infra-Hisian blocks. SA blocks are usually of lesser clinical significance, since in the event
of SA block, the AV node contains a secondary pacemaker which would still maintain a heart rate of around 40 - 60 beats per
minute, sufficient for consciousness and much of daily life in the majority of individuals.

Contents
Types
SA nodal blocks
AV nodal blocks
Infra-Hisian block
 References
External links

Types
Following the path of the electrical signals, the places where
conduction can be blocked give rise to different kinds of heart
blocks:

Location Name
Within the sinoatrial Sinoatrial nodal blocks (often
node (SA node or Sinus abbreviated "SA nodal block" or
node), where the heart's "SA block", sometimes written
signals originate "Sinuatrial block")
Within the Atrioventricular block (often Conduction system of the heart
atrioventricular node abbreviated "AV nodal block",
(AV node) "AV block" or AVB).
At and below the bundle Intra-Hisian blocks and Infra-
of His Hisian blocks respectively.
Within the left or right
Bundle branch blocks.
bundle branches
Within the fascicles of "Fascicular block" or
the left bundle branch hemiblocks.

SA and AV node blocks are each divided into three degrees, with second
degree blocks being divided into two types (written either "type I or II" or
"type 1 or 2"). In an SA block, the electrical impulse is delayed or blocked
on the way to the atria, thus delaying atrial depolarization. By contrast, an
AV block occurs in the AV node and delays ventricular depolarization. The
term "Wenckebach block" is also used for some heart blocks, and can refer to
a second degree type I block in either the SA node or the AV node, however
the ECG features of the two are quite distinctly different.

SA nodal blocks
Types of heart block
SA blocks rarely give severe symptoms, because even if an individual had
complete block at this level of the conduction system (which is uncommon),
the secondary pacemaker of the heart would be at the AV node, which would fire at 40 to 60 beats a minute, which is enough to
retain consciousness in the resting state. However SA block is capable of causing problematic symptoms even so, and may also
hint at conduction issues elsewhere in the heart, and therefore SA blocks are - despite their lower level of life-threatening risk -
still "the most common indication for pacemaker implantation in the US".[3]

Types of SA nodal blocks include:

SA node Wenckebach (Mobitz I)[4]

SA node Mobitz II
SA node exit block
In addition to the above blocks, the SA node can be suppressed by any other arrhythmia that reaches it. This includes retrograde
conduction from the ventricles, ectopic atrial beats, atrial fibrillation, and atrial flutter.
The difference between SA node block and SA node suppression is that in SA
node block an electrical impulse is generated by the SA node that doesn't make
the atria contract. In SA node suppression, on the other hand, the SA node
doesn't generate an electrical impulse because it is reset by the electrical impulse
that enters the SA node.

AV nodal blocks
There are three basic types of AV nodal block: Sinus rhythm with acute inferior
infarction complicated by Type I AV
First-degree AV block block manifest in the form of 5:4
Second-degree AV block Wenckebach periods; R-P/P-R
reciprocity.
Type I second-degree AV block (Mobitz I), also known as
Wenckebach block[5]
Type 2 second-degree AV block (Mobitz II) - due to a block in or
below the bundle of His[5]
Third-degree AV block (complete heart block)

Infra-Hisian block
Infra-Hisian block is that of the distal conduction system. Types of infra-Hisian
block include:
Sinus rhythm (rate = 100/min) with
Type 2 second degree heart block (Mobitz II) –a type of AV block 3:2 and 2:1 Type II AV block; right
due to a block within or below the bundle of His[5]
bundle branch block
Left anterior fascicular block
Left posterior fascicular block
Right bundle branch block
Of these types of infra-Hisian block, Mobitz II heart block is considered most
important because of the possible progression to complete heart block.

References
1. Logan, Carolynn M.; Rice, M. Katherine (1987). Logan's Medical and
Scientific Abbreviations. J. B. Lippincott and Company. p. 232. Sinus tachycardia with complete AV
ISBN 0-397-54589-4. block and resulting junctional escape
2. "Conduction Disorders" (https://www.heart.org/en/health-topics/arrhyt
hmia/about-arrhythmia/conduction-disorders).
sitecoreprod.heart.org|beta.heart.org|www.heart.org|heart.org|*.azurewebsites.net|localhost.
3. Electrocphysiology: A Companion Guide, Steinberg (ed.) (https://books.google.co.uk/books?id=h90AyFfNahsC&
pg=PA144&lpg=PA144&dq=first+degree+infra+hisian+heart+block&source=bl&ots=Rrf31M1TsP&sig=6ewOCF9
Honu6qfNGGD_w5arGsE8&hl=en&sa=X&ved=0CCsQ6AEwAzgKahUKEwjJtY6Du93HAhVBkxQKHXAoCmw#v=
onepage&q&f=false), p. 142
4. Valentin Fuster; R. Wayne Alexander; Robert A. O'Rourke; Robert Roberts; et al. (November 2000). Hurst's The
Heart (10th ed.). McGraw-Hill Professional Publishing. Figure 24–60b. ISBN 978-0-07-135695-4.
5. Dorland's Illustrated Medical Dictionary (32nd ed.). Elsevier. 2012. p. 227. ISBN 978-1-4160-6257-8.

External links
 Classification ICD-10: I44 (http:// D
apps.who.int/classifi
cations/icd10/brows
e/2016/en#/I44)-I45
(http://apps.who.int/
classifications/icd1
0/browse/2016/en#/
I45) · ICD-9-CM:
426.9 (http://www.ic
d9data.com/getICD
9Code.ashx?icd9=4
26.9) · MeSH:
D006327 (https://w
ww.nlm.nih.gov/cgi/
mesh/2015/MB_cg
i?field=uid&term=D
006327) ·
DiseasesDB:
10477 (http://www.d
iseasesdatabase.co
m/ddb10477.htm)

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