Reversibility of High Degree Av Block in Hypertensive and Diabetic Patient with Unstable Angina Pectoris. Should We Delay the Pacemaker?

Introduction: High degree atrioventricular block (HAVB) is a common and potentially life-threatening complication of coronary artery disease (CAD). Studies show that acute myocardial infarction (AMI) is a well-known cause of reversible AV block. Conversely, the study about reversibility of HAVB in patient with CAD other than AMI following revascularization remains limited, especially when the patient has some risk factors associated with AV block. Case Illustration: A 70 year-old man with history of diabetic and hypertension came to emergency department with symptoms of chest pain and shortness of breath. Physical examination showed hypertension, bradycardia, and tachypnea. Electrocardiograms showed total AV block. Laboratory test showed normal troponin. The echocardiography showed positive regional wall motion abnormality with ejection fraction of 42%. Temporary pacemaker implantation was done prior revascularization. Coronary angiography revealed multiple stenosis at left anterior descending artery (LAD). Percutaneous balloon angioplasty was successfully performed. Despite the revascularization, total AV-block still persisted and due to limited facilitation, patient was referred to tertiary hospital to undergo permanent pacemaker (PPM) Discussion: In this case, patient has risk factors that significantly associated both with AV block and CAD. Despite the revascularization, the HAVB in this patient was irreversible. Result: This result is consistent with prior study stating that AVB in CAD without MI is hardly reversible. Thus, it is recommended to not delay the pacemaker implantation Conclusion: HAVB in patients with CAD without MI is rarely reversible. It is also aggravated by the risk factors including hypertension and diabetes. Hence, it is rational to undergo pacemaker implantation earlier