Abstract | November 18, 2023

Intermittent Complete Heart Block in Airforce Engineer

Vagharsh Antanesian, MD, PGY3 Internal Medicine, Norton Community Hospital, Norton, VA;

Michael Jon Lilly, MD, PGY3 Internal Medicine, Norton Community Hospital, Norton, Virginia; Kenny Garcia-Ramiu, MD, PGY3 Internal Medicine, Norton Community Hospital, Norton, Virginia; Rehan Alam, MD, PGY3 Internal Medicine, Norton Community Hospital, Norton, Virginia; Shohan Pervaze, MD PGY2 Internal Medicine, Norton Community Hospital, Norton, Virginia

Learning Objectives

  1. Different degrees of AV block can occur in athletes due to increase vagal tone
  2. Not all AV blocks require pacemaker placement. Some can be treated with medication such as AV block in acute MI or AV block due to Lyme disease
  3. Differentiating complete heart block vs intermittent complete heart block

Introduction
ECG findings such as early repolarization and 1st and 2nd degree AV blocks are well known in competitive sportsman. These rhythms could be benign but might also predispose to dangerous arrhythmias. In this case presentation we will discuss an intermittent complete heart block with junctional escape rhythm in an asymptomatic 46-year-old Airforce engineer who exercises to stay healthy. We will discuss our clinical reasoning for avoiding pacemaker placement

Case Presentation
46-year-old male initially presented local ED with chief complain of chest pain. ED work up was notable for slight elevation in blood pressure and negative troponins. ECG was notable for ST elevation in leads 1 and 2, T-wave inversion in lead 3 and V1. ECHO was unremarkable. Patient was discharged to be followed by PCP with outpatient exercise stress testing.

During stress testing patient was reported to be in type 2 1st degree, AV block which resolved as he started the exercise regimen with max HR of 190 and min HR of 58. He was referred to cardiologist for further management of asymptomatic type 2 heart block.

few months later in cardiologist office he was reported to be in complete heart block with HR of 44 without symptoms and was referred to electrophysiologist (EP) for further management of complete hear block and possible pacemaker placement.

In The EP office patient was found to be in intermittent complete hear block with junction escape rhythm at rate of 40.

Management
During presentation in EP office patient denied any symptoms. He was running average of 17 miles per week in addition to weightlifting without shortness of breath or chest pain. Given narrow complex junctional beats and lack of symptoms It was decided to avoid pacemaker and closely monitor the patient.

Outcome and or Follow-up
Patient tolerated the plan without complication. He continued to stay symptom free and was able to continue his job at airforce.

References and Resources

  1. Estes III, N.A.M (2023). Temporary cardiac pacing. UpToDate. Retrieved May 31, 2023, https://www.uptodate.com/contents/temporary-cardiac-pacing#references
  2. Baggish, A. L., & Wood, M. J. (2011, June 14). Athlete’s heart and cardiovascular care of the athlete. Circulation. https://www.ahajournals.org/doi/10.1161/circulationaha.110.981571
  3. D’Souza, A., Sharma, S., & Boyett, M. R. (2015). CrossTalk opposing view: bradycardia in the trained athlete is attributable to a downregulation of a pacemaker channel in the sinus node. The Journal of physiology, 593(8), 1749–1751. https://doi.org/10.1113/jphysiol.2014.284356
  4. Scharhag, J., Löllgen, H., & Kindermann, W. (2013). Competitive sports and the heart: benefit or risk?. Deutsches Arzteblatt international, 110(1-2), 14–e2. https://doi.org/10.3238/arztebl.2013.0014
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