An 82-year-old patient presents with sudden and frequent dizziness, without prodromes, of short duration and which subsides spontaneously, without ever presenting syncope. Physical examination and baseline electrocardiogram are normal. In an ambulatory electrocardiogram recording during 24 hours, short phases of absence of P waves prior to QRS with an escape rhythm of the atrioventricular junction with narrow QRS at 40 bpm and a wave at the beginning of the ST segment corresponding to a retrograde P were detected in the vigil period. No asystole periods longer than 3 seconds are detected. Given this you would say:
What are these findings in the Holter? If the sinus node fails, the AV node takes over and stimulates the ventricle. In 10% of people there is retrograde conduction, so that beat generated in the AVN stimulates both ventricles and atria, giving a retrograde P as reported in the study. In this sense, no problem. Likewise, there are also no pauses longer than 3 seconds that could cause cardiogenic syncope (which, in fact, he has never suffered). Option 1 is ruled out: it is not a complete AVB. Option 2 cannot be answered either: to exclude, what is said to exclude... It is like never/always. Option 3 does not make much sense: we could suspend those that impair conduction (beta-blockers, calcium antagonists), but drugs that facilitate, as long as we do not give him a perfusion of atropine to take home... In option 4, stating that he has sinoatrial block is a bit of a rap: without an electrophysiological study it cannot be said, he does not necessarily have SA block, and this alone would not indicate the implantation of a pacemaker. So, finally, I would check option 5.
The patient has a third-degree AVB and requires pacemaker implantation.
The absence of periods of asystole >3 seconds excludes a cardiac cause of dizziness.
Drug treatment to increase conduction in the AV node would be indicated.
The patient presents sinus dysfunction with sinoatrial block and requires pacemaker implantation due to symptoms.
The alterations detected in the ambulatory electrocardiogram are typical of patients of this age and there is no indication for therapeutic intervention.
Option 1 is ruled out: it is not a complete AVB.
Option 2 cannot be answered either: to exclude, what is said to exclude... It is like never/always.
Option 3 does not make much sense: we could suspend those that impair conduction (beta-blockers, calcium antagonists), but drugs that facilitate, as long as we do not give him a perfusion of atropine to take home...
In option 4, stating that he has sinoatrial block is a bit of a rap: without an electrophysiological study it cannot be said, he does not necessarily have SA block, and this alone would not indicate the implantation of a pacemaker.