Varying degree of AV block in old lady

A 64 years old female resident of pondicherry (South India) came to JIPMER emergency with chief complaints of giddiness since last one day along with atypical chest pain. There was no histroy of syncope, palpitation, dyspnoea, vomiting. Patient was a known  case hypertension since last one six years and was on tablet metoprolol 50  mg and tablet telmisartan 25 mg once a day. Patient was also giving history of diabetes mellitus and was on oral hypoglycemic agent. There was no history of coroanry artery disease, tuberculosis or any other major illness. During evaluation patient pulse was 38 beats per minute, BP-160/90 mmhg, cardiovascular system S1S2 were normal, Respiratory system was Bilateral normal vesicular sound were present. ECG of the patient done which is shown below

                      ECG 1 (Kindly click on the image to enlarge it)

Description of the ECG- Ventricular rate 38 beats per  minute, atrial rate nearly 116 beats per minute, kindly see ecg closely for every three P wave there is one QRS complex, PR interval is fixed and it is 160 msec, there is left axis deviation in view of positive QRS in lead I and negative QRS in lead avF,  QRS complex suggestive of incomplete RBBB  morphology in lead V1 and in lead V6, Deep T inversion seen in lead V4,V6, also there is T wave inversion seen in lead II,III,avF,avL, QT interval  480 msec, QTc interval 382 msec,so the ECG is suggestive of 3:2 Type II Mobitz type II AV nodal block (High grade block)

                                                                
                                                                      ECG 2

Second ECG of the patient suggestive of Complete AV dissociation with atrial rate around 116 beats per minute, Junctional escape rhythm at rate 38 beats per minute, there is no relation between P wave and QRS complex , QT interval 600 msec, QTc interval 477 msec so the ECG of the patient was suggestive of complete heart block.

           Again ECG of the patient repeated after 2 minute, ECG 3

ECG is suggestive of atrial rate around 115 beats per minute, ventricular rate 38 beats per minute, there are two P wave for each one QRS complex, PR interval is 520 msec, there is left axis deviation, QRS complex of RBBB morphology QRS duration 120 msec, QT interval 480 msec, QTc interval 382 msec so the ECG is suggestive of 2:1 Mobitz type II, AV node type II block which is a high grade block.

Patient beta blocker stoped but her block did not improved even after four days of stoping of beta blocker so decision to put pacemaker was taken. Pacemaker was inserted and patient was discharged from the hospital in stable condition.


Thank you.