Case report
Sudden cardiac arrest due to atrioventricular block: A diagnostic challenge
Paragem súbita cardíaca devida a bloqueio auriculoventricular: um desafio de diagnóstico
Francisco Javier Irazusta
, Adrian Rivas, Sandra Rosillo, Veronica Rial, Elena Refoyo, Raul Moreno, Esteban Lopez de Sa, Jose Luis Lopez-Sendon
Corresponding author
Cardiology Department, La Paz University Hospital, Madrid, Spain
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Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "rev" "cita" => "Rev Port Cardiol. 2018;37:935-45" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 695 "formatos" => array:3 [ "EPUB" => 85 "HTML" => 419 "PDF" => 191 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review Article</span>" "titulo" => "A 2018 overview of diuretic resistance in heart failure" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "935" "paginaFinal" => "945" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "A resistência aos diuréticos na insuficiência cardíaca revisitada em 2018" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1943 "Ancho" => 2583 "Tamanyo" => 340799 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Pathophysiology-based approach to diuretic resistance.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sofia Isabel Jardim, Luís Ramos dos Santos, Inês Araújo, Filipa Marques, Patrícia Branco, Augusta Gaspar, Cândida Fonseca" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Sofia Isabel" "apellidos" => "Jardim" ] 1 => array:2 [ "nombre" => "Luís" "apellidos" => "Ramos dos Santos" ] 2 => array:2 [ "nombre" => "Inês" "apellidos" => "Araújo" ] 3 => array:2 [ "nombre" => "Filipa" "apellidos" => 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array:8 [ 0 => array:4 [ "nombre" => "Francisco Javier" "apellidos" => "Irazusta" "email" => array:1 [ 0 => "firazusta88@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Adrian" "apellidos" => "Rivas" ] 2 => array:2 [ "nombre" => "Sandra" "apellidos" => "Rosillo" ] 3 => array:2 [ "nombre" => "Veronica" "apellidos" => "Rial" ] 4 => array:2 [ "nombre" => "Elena" "apellidos" => "Refoyo" ] 5 => array:2 [ "nombre" => "Raul" "apellidos" => "Moreno" ] 6 => array:2 [ "nombre" => "Esteban Lopez" "apellidos" => "de Sa" ] 7 => array:2 [ "nombre" => "Jose Luis" "apellidos" => "Lopez-Sendon" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Cardiology Department, La Paz University Hospital, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Paragem súbita cardíaca devida a bloqueio auriculoventricular: um desafio de diagnóstico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1805 "Ancho" => 2267 "Tamanyo" => 271581 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Cardiac magnetic resonance: A) Increased short inversion time inversion recovery signal intensity, indicating septal edema. B) Subendocardial perfusion defect in the same area. C and D) Transmural delayed enhancement at the same level with no viability, confirming the diagnosis of acute septal myocardial infarction.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">We report the case of a 62-year-old woman, born in Cuba, who had been living in Spain for 5 years at the time of the event. She had a long-standing history of hypertension, dyslipidemia and was an active smoker.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The woman in question was walking down the street when she suddenly suffered a witnessed cardiac arrest. Basic cardiopulmonary resuscitation (CPR) maneuvers were performed for 15 minutes following medical instructions provided by telephone. The emergency outpatient services then started advanced CPR, after registering pulseless electrical activity on the initial electrocardiogram (ECG). Spontaneous circulation eventually returned and the ECG showed a third-degree AV block (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was transferred to our hospital under neurological sedation and invasive mechanical ventilation. She was also receiving intravenous inotropic agents and transcutaneous pacemaker stimulation. The patient was admitted to the Coronary Unit where mild therapeutic hypothermia was induced after a temporary transvenous pacemaker was implanted. A blood test revealed neutrophilic leukocytosis, increased acute phase reactants and elevated myocardial damage markers (Troponin I peak 21 ng/ml [normal threshold <0.05 ng/ml]), while the ECG showed a pacemaker-stimulated ventricular rhythm with AV dissociation (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B).</p><p id="par0020" class="elsevierStylePara elsevierViewall">A transthoracic echocardiogram was suboptimal due to a poor acoustic window, so a transesophageal echocardiogram was performed, revealing mildly reduced left ventricular function with akinesia of the mid and basal segments of the interventricular septum.</p><p id="par0025" class="elsevierStylePara elsevierViewall">On suspicion of acute coronary syndrome (ACS), a coronary angiogram was performed. The patient was diagnosed with diffuse triple-vessel coronary artery disease, but no severe obstructive lesions were reported (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The patient's family stated that she had not suffered previous episodes of chest pain, but mentioned that she had had flu-like symptoms in the week prior to admission. Given the data obtained thus far, acute viral myocarditis was thought to perhaps be the trigger behind the high-grade AV block and cardiac arrest, so corticosteroids were administered empirically.</p><p id="par0035" class="elsevierStylePara elsevierViewall">During her hospital stay, good neurological status was confirmed by a sedation window, which enabled early extubation after normothermia was achieved. After 72 hours, AV conduction was recovered, initially with complete right bundle branch block, albeit with further QRS narrowing until complete normalization (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>C).</p><p id="par0040" class="elsevierStylePara elsevierViewall">Finally, cardiac magnetic resonance (CMR) imaging was performed, confirming abnormal interventricular septum contractility. An increased short inversion time inversion recovery signal intensity was also observed, indicating edema. Moreover, a subendocardial perfusion defect, alongside transmural delayed enhancement at the same level with no viability, confirmed the diagnosis of acute septal myocardial infarction (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The coronary angiogram was reviewed and the absence of the first septal branch of the left coronary artery was corroborated, with its occlusion being assumed to be the trigger behind the AV block and cardiac arrest.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Standard treatment for ACS was initiated and the indication for permanent pacing was referred to the Heart Team, who ultimately decided against implantation owing to the ischemic etiology of the transient AV block, which had already been resolved. The patient then completed a cardiac rehabilitation program and has remained asymptomatic ever since.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">This particular case shows how difficult a differential diagnosis of ACS and acute viral myocarditis can be, especially if associated with cardiac arrest. Neither the patient's demographic characteristics, blood test results, ECG nor echocardiogram allowed us to be sure of the diagnosis. Moreover, even though the most common cause of cardiac arrest is ischemic heart disease, here the initial coronary angiogram was inconclusive.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In patients with suspected ACS but no coronary obstructive lesions on the coronary angiogram, CMR may prove very useful, since it can detect subtle and reversible coronary events (distal or small arteries, vasospasm).<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> CMR enables an accurate differential diagnosis of ACS and myocarditis. Unlike myocarditis, ACS is accompanied by decreased myocardial perfusion in anatomically delimited vascular segments, in addition to characteristic subendocardial or transmural late gadolinium enhancement.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Another point of discussion is the indication for permanent pacing. When transient, third-degree AV block secondary to ACS has no indication for permanent pacing.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> In this case, where the AV block involved cardiac arrest, the decision was even more important due to its potential prognostic implications. Despite the diagnosis of ACS, for which the patient did not undergo reperfusion therapy, the ECG at discharge did not reveal marked electrical conduction abnormalities besides the QS wave shown in V1 and V2 (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>C). However, care must be taken with an ECG alteration such as this, since placing ECG leads higher up on the chest wall can generate this finding even without the presence of a myocardial infarction.</p><p id="par0070" class="elsevierStylePara elsevierViewall">A similar situation occurs during percutaneous alcohol septal ablation for the treatment of hypertrophic obstructive cardiomyopathy. A high percentage of these patients require a temporary pacemaker in the early post-ablation period, but ultimately less than 10% require permanent pacing due to persistent AV blockage.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In conclusion, this case allows us to assess the importance of the differential diagnosis of ACS and acute myocarditis. On the one hand, CMR can provide important information to distinguish between both etiologies, while on the other, it is important to highlight that an AV block related to ACS involving the septum does not always require permanent pacing as long as the patient fully recovers AV conduction after the acute phase.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:3 [ "identificador" => "xres1127650" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1061253" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1127649" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1061252" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-01-13" "fechaAceptado" => "2017-08-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1061253" "palabras" => array:6 [ 0 => "Cardiac arrest" 1 => "Acute coronary syndrome" 2 => "Myocarditis" 3 => "Atrioventricular block" 4 => "Cardiac magnetic resonance" 5 => "Pacemaker" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec1061252" "palabras" => array:6 [ 0 => "Paragem cardíaca" 1 => "Síndrome coronária aguda" 2 => "Miocardite" 3 => "Bloqueio auriculoventricular" 4 => "Ressonância magnética" 5 => "<span class="elsevierStyleItalic">Pacemaker</span>" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sudden cardiac arrest survivors continue to be a challenge for cardiologists. An appropriate initial diagnostic approach is crucial for planning a successful therapeutic strategy. We report the case of a 62-year-old woman who suffered an out-of-hospital cardiac arrest due to third-degree atrioventricular (AV) block. Despite suspected acute coronary syndrome, the coronary angiogram proved inconclusive, while cardiac magnetic resonance imaging ruled out other differential diagnoses such as acute myocarditis. The reversible nature of the AV block rendered permanent pacing unnecessary.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Os sobreviventes de uma paragem súbita cardíaca ainda constituem um desafio para os cardiologistas. Uma abordagem de diagnóstico inicial apropriada é crucial para o planeamento de uma estratégia terapêutica bem sucedida. Apresentamos o caso de uma mulher de 62 anos que sofreu uma paragem cardíaca fora do hospital devida a bloqueio auriculoventricular de terceiro grau. Apesar de suspeita clínica inicial de síndrome coronária aguda, a angiografia coronária foi inconclusiva enquanto a ressonância magnética foi decisiva para excluir outros diagnósticos diferenciais, tais como miocardite aguda. A natureza reversível do bloqueio auriculoventricular evitou a implantação de um <span class="elsevierStyleItalic">pacemaker</span> permanente.</p></span>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2233 "Ancho" => 2833 "Tamanyo" => 579185 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Electrocardiograms: A) Third-degree atrioventricular block during advanced cardiopulmonary resuscitation. B) Pacemaker-stimulated ventricular rhythm with atrioventricular dissociation. C) Sinus rhythm with normal atrioventricular conduction and narrow QRS.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1700 "Ancho" => 2267 "Tamanyo" => 325176 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Coronary angiogram: A) Left anterior descending artery with diffuse atherosclerosis but no apparent severe obstructive lesions. B) Left coronary artery, circumflex artery branches and left anterior descending artery from another point of view. C) Right coronary artery.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1805 "Ancho" => 2267 "Tamanyo" => 271581 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Cardiac magnetic resonance: A) Increased short inversion time inversion recovery signal intensity, indicating septal edema. B) Subendocardial perfusion defect in the same area. C and D) Transmural delayed enhancement at the same level with no viability, confirming the diagnosis of acute septal myocardial infarction.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The value of cardiac magnetic resonance in patients with acute coronary syndrome and normal coronary arteries" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "E. Laraudogoitia Zaldumbide" 1 => "E. Pérez-David" 2 => "J.A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 2 | 11 |
| 2024 October | 35 | 27 | 62 |
| 2024 September | 43 | 30 | 73 |
| 2024 August | 43 | 26 | 69 |
| 2024 July | 43 | 41 | 84 |
| 2024 June | 28 | 39 | 67 |
| 2024 May | 30 | 27 | 57 |
| 2024 April | 39 | 25 | 64 |
| 2024 March | 37 | 32 | 69 |
| 2024 February | 24 | 35 | 59 |
| 2024 January | 35 | 32 | 67 |
| 2023 December | 22 | 27 | 49 |
| 2023 November | 29 | 28 | 57 |
| 2023 October | 19 | 22 | 41 |
| 2023 September | 24 | 20 | 44 |
| 2023 August | 25 | 23 | 48 |
| 2023 July | 32 | 17 | 49 |
| 2023 June | 28 | 19 | 47 |
| 2023 May | 42 | 33 | 75 |
| 2023 April | 26 | 4 | 30 |
| 2023 March | 45 | 19 | 64 |
| 2023 February | 38 | 17 | 55 |
| 2023 January | 31 | 25 | 56 |
| 2022 December | 55 | 28 | 83 |
| 2022 November | 41 | 32 | 73 |
| 2022 October | 66 | 23 | 89 |
| 2022 September | 61 | 40 | 101 |
| 2022 August | 84 | 42 | 126 |
| 2022 July | 80 | 36 | 116 |
| 2022 June | 64 | 29 | 93 |
| 2022 May | 74 | 33 | 107 |
| 2022 April | 53 | 27 | 80 |
| 2022 March | 54 | 35 | 89 |
| 2022 February | 28 | 30 | 58 |
| 2022 January | 43 | 21 | 64 |
| 2021 December | 48 | 31 | 79 |
| 2021 November | 82 | 45 | 127 |
| 2021 October | 143 | 42 | 185 |
| 2021 September | 201 | 27 | 228 |
| 2021 August | 39 | 31 | 70 |
| 2021 July | 35 | 23 | 58 |
| 2021 June | 40 | 35 | 75 |
| 2021 May | 115 | 55 | 170 |
| 2021 April | 146 | 86 | 232 |
| 2021 March | 97 | 33 | 130 |
| 2021 February | 61 | 24 | 85 |
| 2021 January | 62 | 23 | 85 |
| 2020 December | 41 | 16 | 57 |
| 2020 November | 31 | 11 | 42 |
| 2020 October | 22 | 15 | 37 |
| 2020 September | 26 | 20 | 46 |
| 2020 August | 16 | 15 | 31 |
| 2020 July | 22 | 9 | 31 |
| 2020 June | 23 | 12 | 35 |
| 2020 May | 32 | 14 | 46 |
| 2020 April | 24 | 11 | 35 |
| 2020 March | 25 | 17 | 42 |
| 2020 February | 56 | 24 | 80 |
| 2020 January | 15 | 8 | 23 |
| 2019 December | 20 | 7 | 27 |
| 2019 November | 14 | 17 | 31 |
| 2019 October | 16 | 4 | 20 |
| 2019 September | 28 | 9 | 37 |
| 2019 August | 19 | 10 | 29 |
| 2019 July | 22 | 10 | 32 |
| 2019 June | 22 | 20 | 42 |
| 2019 May | 19 | 8 | 27 |
| 2019 April | 14 | 13 | 27 |
| 2019 March | 12 | 16 | 28 |
| 2019 February | 9 | 9 | 18 |
| 2019 January | 27 | 7 | 34 |
| 2018 December | 13 | 20 | 33 |
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