High-grade Atrioventricular Block in Acute Coronary Syndromes
High-grade Atrioventricular Block in Acute Coronary Syndromes
Background While prior work has suggested that a high-grade atrioventricular block (HAVB) in the setting of an acute coronary syndrome (ACS) is associated with in-hospital death, limited information is available on the incidence of, and death associated with, HAVB in ACS patients receiving contemporary management.
Methods and results The incidence of HAVB was determined within The Global Registry of Acute Coronary Events (GRACE). The clinical characteristics, in-hospital therapies, and outcomes were compared between patients with and without HAVB. Factors associated with death in patients with HAVB were determined. A total of 59 229 patients with ACS between 1999 and 2007 were identified; 2.9% of patients had HAVB at any point during the index hospitalization; 22.7% of whom died in hospital [adjusted odds ratio (OR) = 4.2, 95% confidence interval (CI), 3.6–4.9, P < 0.001]. The association between HAVB and in-hospital death varied with type of ACS [OR: ST-segment elevation myocardial infarction (STEMI) = 3.0; non-STEMI = 6.4; unstable angina = 8.2, P for interaction < 0.001]. High-grade atrioventricular block present at the time of presentation to hospital (vs. occurring in-hospital) and early (<12 h) percutaneous coronary intervention or fibrinolysis (vs.>12 h or no intervention) were associated with improved in-hospital survival, whereas temporary pacemaker insertion was not. Patients with HAVB surviving to discharge had similar adjusted survival at 6 months compared with those without HAVB. A reduction in the rate of, but not in-hospital mortality associated with, HAVB was noted over the study period.
Conclusion Although the incidence of HAVB is low and decreasing, this complication continues to have a high risk of in-hospital death.
High-grade atrioventricular block (HAVB), defined as the presence of Mobitz type II second-degree or third-degree AV block, is a worrisome finding in patients with acute coronary syndromes (ACS). Prior studies have reported the incidence of HAVB in ACS between 3 and 14% with an associated three- to five-fold increased risk of in-hospital death. These reports have been limited by the small numbers of patients studied, typically in ST segment myocardial infarction (STEMI) patients, and predominantly in patients receiving care in, or prior to, the 1990s. Furthermore, the associations between clinical factors including in-hospital therapies received, and the risk of death within this group of patients is not well described. To address these limitations, we analysed data from a global population of ACS patients to determine: (i) the incidence of HAVB complicating ACS, (ii) the risk of death, and (iii) factors associated with death in patients with HAVB.
Abstract and Introduction
Abstract
Background While prior work has suggested that a high-grade atrioventricular block (HAVB) in the setting of an acute coronary syndrome (ACS) is associated with in-hospital death, limited information is available on the incidence of, and death associated with, HAVB in ACS patients receiving contemporary management.
Methods and results The incidence of HAVB was determined within The Global Registry of Acute Coronary Events (GRACE). The clinical characteristics, in-hospital therapies, and outcomes were compared between patients with and without HAVB. Factors associated with death in patients with HAVB were determined. A total of 59 229 patients with ACS between 1999 and 2007 were identified; 2.9% of patients had HAVB at any point during the index hospitalization; 22.7% of whom died in hospital [adjusted odds ratio (OR) = 4.2, 95% confidence interval (CI), 3.6–4.9, P < 0.001]. The association between HAVB and in-hospital death varied with type of ACS [OR: ST-segment elevation myocardial infarction (STEMI) = 3.0; non-STEMI = 6.4; unstable angina = 8.2, P for interaction < 0.001]. High-grade atrioventricular block present at the time of presentation to hospital (vs. occurring in-hospital) and early (<12 h) percutaneous coronary intervention or fibrinolysis (vs.>12 h or no intervention) were associated with improved in-hospital survival, whereas temporary pacemaker insertion was not. Patients with HAVB surviving to discharge had similar adjusted survival at 6 months compared with those without HAVB. A reduction in the rate of, but not in-hospital mortality associated with, HAVB was noted over the study period.
Conclusion Although the incidence of HAVB is low and decreasing, this complication continues to have a high risk of in-hospital death.
Introduction
High-grade atrioventricular block (HAVB), defined as the presence of Mobitz type II second-degree or third-degree AV block, is a worrisome finding in patients with acute coronary syndromes (ACS). Prior studies have reported the incidence of HAVB in ACS between 3 and 14% with an associated three- to five-fold increased risk of in-hospital death. These reports have been limited by the small numbers of patients studied, typically in ST segment myocardial infarction (STEMI) patients, and predominantly in patients receiving care in, or prior to, the 1990s. Furthermore, the associations between clinical factors including in-hospital therapies received, and the risk of death within this group of patients is not well described. To address these limitations, we analysed data from a global population of ACS patients to determine: (i) the incidence of HAVB complicating ACS, (ii) the risk of death, and (iii) factors associated with death in patients with HAVB.
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