01Approach to the Critical Patient/attcp56

Immediate stabilization

›Hemodynamic instability triggers

›Hypotension (SBP < 90 mmHg) with bradycardia

›Transcutaneous pacing pads applied immediately

›Activate transcutaneous pacing if hemodynamically unstable

›Target rate 60-80 beats/min with transcutaneous pacing

›Altered mental status or syncope with bradycardia

›Place patient supine with legs elevated

›IV access x2 large bore

›Signs of cardiogenic shock

›Hypoperfusion with cool extremities

›Elevated lactate >= 2 mmol/l

›Airway and oxygenation targets

›SpO2 target >= 94%

›Supplemental oxygen for hypoxic patients

›Intubation readiness if altered mental status or hemodynamic collapse

›Rhythm identification priorities

›12-lead ECG within 10 minutes of arrival

›Fixed PR interval in conducted beats

›Intermittent dropped QRS without preceding PR prolongation

›Wide vs. narrow QRS determination critical for risk stratification

›Continuous telemetry monitoring mandatory

›AHA Class I recommendation for hospital ECG monitoring in high-grade block

›Distinguish from other AV block types immediately

Critical decision points

›Pacing urgency stratification

›Emergent transcutaneous pacing

›Hemodynamic instability despite initial resuscitation

02History/hx95

Presenting symptoms

›Cardinal symptoms

›Syncope or Stokes-Adams attacks

›Abrupt onset without prodrome distinguishes from vasovagal

›Hallmark symptom noted by Mobitz in original description

›Presyncope and dizziness

›Lightheadedness with positional changes

›Graying of vision

›Palpitations

›Awareness of skipped beats or pauses

›Sensation of heart stopping

›Associated symptoms

›Fatigue and exercise intolerance

›Reduced cardiac output with bradycardia

›Exertional worsening suggests infranodal disease

›Dyspnea

›Exertional dyspnea

›Orthopnea or PND if heart failure present

›Chest pain

›Ischemic etiology must be excluded

›Anterior MI supplies His bundle and bundle branches via LAD

Timeline and context

›Symptom duration and pattern

›Episodic vs. persistent symptoms

›Exertional worsening vs. rest occurrence

›Prior episodes of syncope or documented bradycardia

›Triggering or preceding events

›Recent medication changes

›New beta-blocker, calcium channel blocker, digoxin

›New antiarrhythmic initiation

›Recent cardiac procedures

›Cardiac surgery

›Catheterization or ablation

›TAVR (high risk for conduction disturbance)

›Recent viral illness or flu-like prodrome

›Myocarditis possibility

›Tick exposure or travel to Lyme-endemic areas

›Lyme carditis is reversible cause

Risk factors and medical history

›Cardiac history

›Prior MI especially anterior wall

›LAD territory supplies His bundle and proximal bundle branches

›Known coronary artery disease

›Structural heart disease or cardiomyopathy

›Valvular heart disease

›Prior bundle branch block (RBBB or LBBB)

›Strongest ECG predictor of progression to complete heart block

›Bifascicular block history

›Systemic conditions

›Degenerative fibrosis of conduction system (age-related, most common cause)

›Chronic hypertension

›Diabetes mellitus

›Both associated with AV block in JAMA Network Open 2019 registry study

›Infiltrative cardiomyopathy

›Cardiac sarcoidosis

›Cardiac amyloidosis

›Autoimmune/inflammatory

›Systemic lupus erythematosus

›Rheumatoid arthritis

›Infectious endocarditis

›Perivalvular abscess extending to conduction system

›Neuromuscular diseases

›Myotonic dystrophy type 1

›Emery-Dreifuss muscular dystrophy

›Limb-girdle muscular dystrophy

›Kearns-Sayre syndrome

›All associated with progressive conduction system disease per ACC/AHA/HRS 2018

Medications review

›AV nodal blocking agents

›Beta-blockers

›Primarily slow AV nodal conduction

›Mobitz II on these agents often reveals severe underlying infranodal disease

›Non-dihydropyridine calcium channel blockers

›Verapamil

›Diltiazem

›Digoxin

›Therapeutic level does not exclude toxicity as contributing factor

›Antiarrhythmic agents

›Class Ic agents

›Flecainide

›Propafenone

›Class III agents

›Amiodarone

›Sotalol

›Drug-induced vs. drug-revealed distinction

›~50% of patients have block recurrence after drug discontinuation

›Per ACC/AHA/HRS: reasonable to pace without waiting for washout if medically necessary (Class IIa)

›Other implicated agents

›Fingolimod (sphingosine-1-phosphate receptor modulator)

Family and social history

›Family history

›Sudden cardiac death in first-degree relatives

›Pacemaker implantation in young family members

›Known hereditary conduction disease

›Lamin A/C gene mutations

›Associated with progressive AV block and sudden death risk

›Social history

›Outdoor activities in tick-endemic areas

›IV drug use (endocarditis risk)

›Alcohol use (cardiomyopathy, electrolyte disturbances)

03Physical Exam/exam50

Vital signs

›Cardiovascular vital sign assessment

›Heart rate

›Bradycardia with regular rhythm interrupted by pauses

›Rate may be deceivingly normal in 2:1 block

›Blood pressure

›Hypotension indicates hemodynamic compromise

›Pulse pressure narrowing with low cardiac output

›Respiratory rate

›Tachypnea may indicate pulmonary edema or low output state

›SpO2 on room air

Cardiovascular exam

›Pulse and rhythm

›Irregular pulse with intermittent pauses

›Pause duration equals exactly 2 PP intervals

›Distinguishes from PAC-induced pauses

›Pulse deficit assessment

›Radial vs. apical pulse comparison

›Jugular venous pulsations

›Cannon A waves

›Occur when atria contract against closed tricuspid valve during blocked beat

›Intermittent rather than regular (unlike complete heart block)

›Elevated JVP suggests right heart failure or pericardial disease

›Cardiac auscultation

›Variable S1 intensity (less variable than complete heart block, PR is fixed in conducted beats)

›S3 gallop suggests left ventricular dysfunction

›Murmurs

›Aortic stenosis as structural cause

04Differential Diagnosis/ddx54

High-grade AV block variants

›Mobitz Type I (Wenckebach) AV block

›ICD-10: I44.1

›Progressive PR prolongation before dropped beat

›Generally benign, AV nodal in origin

›Responds to atropine unlike Mobitz II

›Differentiating feature: PR not fixed between conducted beats

›Complete (Third-Degree) AV block

›ICD-10: I44.2

›Complete AV dissociation, no relationship between P waves and QRS

›Escape rhythm maintains ventricular rate independently

›May be the outcome of untreated or progressed Mobitz II

›High-Grade (Advanced) AV block

›ICD-10: I44.30

›Two or more consecutive non-conducted P waves

›Treated similarly to Mobitz II per ACC/AHA/HRS 2018

ECG mimics

›2:1 AV block

›Cannot be classified as Mobitz I or II from a single ECG strip

›Requires longer monitoring or maneuvers to reveal true block pattern

›Exercise test or carotid sinus massage may unmask pattern

›Pseudo-Mobitz II

›Vagally mediated block with sinus slowing before dropped beat

›Distinguishing feature: sinus rate is NOT constant (true Mobitz II has constant PP intervals)

›Generally benign and responds to atropine

›Blocked premature atrial complexes

›ICD-10: I49.1

›P waves hidden within preceding T waves mimicking dropped beats

05Laboratory Tests/lt56

Cardiac biomarkers

›Troponin

›Troponin I or T (high-sensitivity preferred)

›Elevated in acute MI as etiology of Mobitz II

›Anterior MI may cause infranodal block via LAD territory ischemia

›Serial troponins 0 and 3 hours if ischemia suspected

›BNP or NT-proBNP

›Elevated with associated heart failure

›Guides level-of-care decisions

Metabolic panel

›Basic metabolic panel

›Potassium

›Hyperkalemia can exacerbate conduction disease

›Target 4.0-5.0 mmol/l

›Calcium

›Hypercalcemia may affect AV conduction

›Magnesium

›Hypomagnesemia can worsen conduction disturbances

›Target 0.75-1.0 mmol/l

›Creatinine and eGFR

›Renal function affects drug dosing for temporizing agents

›Glucose

›Hypoglycemia may mimic syncope

›Complete blood count

›Hemoglobin

›Anemia worsens cardiac output compromise

›White blood cell count

›Leukocytosis with infectious etiology (Lyme, endocarditis)

06Diagnostic Tests/dt70

Scoring Systems

›AV block risk stratification

›Wide QRS (> 120 ms) with Mobitz II

›Indicates diffuse His-Purkinje disease

›Highest risk of sudden progression to complete heart block

›Class I indication for pacemaker regardless of symptoms per ACC/AHA/HRS 2018

›Narrow QRS Mobitz II

›Less common; may represent intra-Hisian block

›Class IIa indication for pacemaker per ACC/AHA/HRS 2018

›2018 ACC/AHA/HRS Bradycardia Guideline Algorithm

›Identifies reversible causes before committing to permanent pacing

›Stratifies by symptoms, QRS width, and LV function

›LVEF thresholds for device selection

›LVEF > 35%

›Standard dual-chamber pacemaker appropriate

›LVEF <= 35% with anticipated RV pacing > 40%

›Cardiac resynchronization therapy (CRT) preferred

›CRT-D if concomitant SCD risk

›HV interval on electrophysiology study

›HV >= 70 ms indicates significant infranodal disease

›Supports pacemaker implantation even with ambiguous surface ECG

MRI

›Cardiac MRI indications

›Suspected infiltrative cardiomyopathy

›Cardiac sarcoidosis: patchy mid-myocardial or subepicardial late gadolinium enhancement

›Cardiac amyloidosis: diffuse subendocardial or transmural LGE with characteristic kinetics

›Myocarditis evaluation

›Lake Louise criteria: T2-weighted edema, LGE, T1 mapping

07Disposition/dispo39

Admission criteria

›Mandatory admission for all confirmed Mobitz II

›ACC/AHA/HRS 2018: all patients with Mobitz II require monitored admission until pacemaker implantation

›Risk of sudden unpredictable progression to complete heart block

›Stokes-Adams attacks and sudden death without warning

›Continuous telemetry monitoring throughout admission

›AHA scientific statement on ECG monitoring standards

›ICU/CCU level care indications

›Hemodynamic instability

›Hypotension requiring vasopressors

›Cardiogenic shock

›Active transcutaneous or transvenous pacing requirement

›Frequent or prolonged symptomatic pauses

›Concurrent STEMI with infranodal block

Monitored bed criteria

›Stepdown or telemetry unit

›Hemodynamically stable symptomatic patients

›Syncope or presyncope without current instability

›Awaiting electrophysiology consultation and pacemaker planning

›Asymptomatic Mobitz II confirmed on ECG

›Still requires monitored admission; block is unpredictable

Discharge criteria

›Only following one of:

›Permanent pacemaker implanted with confirmed appropriate device function

›Device interrogation confirms appropriate sensing and pacing thresholds

›Reversible cause fully treated with documented resolution of AV block

›Lyme carditis: documented return to normal conduction after antibiotics

›Drug toxicity: block resolved after washout with close follow-up arranged

08Treatment/t101

Immediate bridging therapies

›Transcutaneous pacing

›Indications

›Hemodynamic instability

›Symptomatic high-degree or complete AV block

›Immediate bridge while transvenous pacing is prepared

›Technique

›Pads placed anteroposteriorly (preferred) or anterior-lateral

›Rate set at 60-80 beats/min

›Output titrated from low to threshold for capture

›Confirm electrical and mechanical capture

›Sedation/analgesia

›Fentanyl 25-50 mcg IV for pain

›Midazolam 1-2 mg IV for sedation

›Ketamine 0.5-1 mg/kg IV if hypotensive

›Temporary transvenous pacing

›Indications

›Hemodynamic compromise not resolved by transcutaneous pacing

›Bridge to permanent pacemaker in unstable patient

›Class I per ACC/AHA/HRS 2018

›Access

›Right internal jugular or left subclavian preferred for stability

›Femoral route if other access not feasible

›Parameters

›Rate 60-80 beats/min

›Output at 2x threshold for reliable capture

›Sensitivity at appropriate setting to avoid undersensing

Pharmacologic temporizing agents

›Isoproterenol

›Mechanism: beta-1 and beta-2 agonist increasing His-Purkinje automaticity

›Indication: temporizing if pacing unavailable and no ischemia risk

›Dosing

›2-10 mcg/min IV infusion

›Titrate to achieve adequate ventricular rate

›Avoid in ischemic heart disease (increases myocardial oxygen demand)

›Class IIb recommendation per ACC/AHA/HRS 2018

›Dopamine

›Dosing

›2-20 mcg/kg/min IV infusion

›Titrate to heart rate and blood pressure targets

›Alternative if isoproterenol unavailable or ischemia concern

›Epinephrine

›Dosing

›2-10 mcg/min IV infusion

›Titrate to hemodynamic response

›Last resort agent for refractory hemodynamic collapse with bradycardia

›Atropine

›Generally NOT recommended in Mobitz II

›Ineffective for infranodal block

›May paradoxically worsen block

›By increasing sinus rate, overwhelms diseased His-Purkinje system

›Consider only if Mobitz I (Wenckebach) cannot be excluded

›Aminophylline

›IV aminophylline 250 mg over 20 minutes

›Considered in acute inferior MI with bradycardia

›Adenosine antagonism may improve AV conduction

›Evidence limited; use as adjunct only

Reversible cause treatment

›Lyme carditis

›High-degree block: IV ceftriaxone 2g daily for 14-21 days

›Temporary pacing while awaiting antibiotic response

›Do not implant permanent pacemaker until block fails to resolve

›Lower-degree block: oral doxycycline 100 mg twice daily for 14-21 days

›Block typically resolves within days to weeks

›Drug toxicity

›Digoxin toxicity: digoxin-specific Fab fragments (Digibind/DigiFab)

›Dose calculated from serum level or total body load

›40 mg vial neutralizes approximately 0.5 mg digoxin

›Discontinue offending AV-blocking agents

›Electrolyte correction

›Potassium target 4.0-5.0 mmol/l

›Magnesium target >= 0.75 mmol/l

›Acute MI

›Emergency revascularization (PCI) for STEMI with infranodal block

›Anterior MI: LAD revascularization may not restore conduction if His-Purkinje permanently damaged

›Temporary pacing until conduction assessment post-revascularization

Definitive treatment: permanent pacemaker

›Class I indications (per ACC/AHA/HRS 2018)

›Acquired Mobitz II not attributable to reversible or physiologic causes

›Regardless of symptoms

›Asymptomatic Mobitz II with wide QRS (> 120 ms)

›High risk of sudden unpredictable progression

›Symptomatic Mobitz II regardless of QRS width

›Class IIa indications

›Asymptomatic Mobitz II with narrow QRS

›Less common; intra-Hisian disease possible

›Device selection

›Standard dual-chamber pacemaker (DDD)

›LVEF > 35% with expected low RV pacing burden

›Maintains AV synchrony

›Cardiac resynchronization therapy (CRT or CRT-D)

›LVEF <= 35% with anticipated RV pacing > 40%

›Prevents pacing-induced cardiomyopathy

›CRT-D if SCD risk stratification warrants defibrillator

›Pacemaker with defibrillator (ICD or CRT-D)

›Infiltrative cardiomyopathy (sarcoidosis, amyloidosis)

›Lamin A/C mutation carriers

›His bundle pacing or left bundle branch area pacing

›Alternative to RV pacing to preserve physiologic conduction

›Emerging evidence; consider in appropriate anatomy

›Post-implant management

›Device interrogation before discharge

›Sensing and pacing threshold confirmation

›Arm movement restrictions for 2-4 weeks (pectoral implant)

›Avoid electromagnetic interference sources

09Special Populations/sp89

Pregnancy

›Incidence and risk in pregnancy

›Mobitz II in pregnancy is rare; most conduction disease in pregnancy is first-degree

›Lyme carditis and drug-induced block are important reversible causes

›Peripartum cardiomyopathy may occasionally produce conduction disease

›Physiologic changes affecting management

›Increased heart rate in normal pregnancy (10-15 bpm above baseline)

›May partially mask bradycardia in mild cases

›Increased plasma volume and cardiac output demands

›Poorly tolerated bradycardia relative to non-pregnant state

›Aortocaval compression in supine position

›Left lateral decubitus positioning required

›Treatment modifications

›Transcutaneous and transvenous pacing safe in pregnancy

›Preferred over pharmacotherapy in hemodynamically significant block

›Isoproterenol: use with extreme caution

›May cause uterine relaxation

›Avoid in first trimester; limited data

›Permanent pacemaker implantation

›Can be performed in pregnancy with appropriate radiation minimization

›Fluoroscopy time minimized; lead-lined apron

›ICE guidance or echocardiographic guidance to reduce fluoroscopy

›Lyme treatment in pregnancy

›IV ceftriaxone 2g daily preferred over doxycycline

›Doxycycline contraindicated in second and third trimesters

›Delivery planning

›Multidisciplinary team: cardiology, maternal-fetal medicine, anesthesia

›Continuous telemetry during labor and delivery

›Transcutaneous pacing pads applied

Geriatric

›Epidemiology in older adults

›Degenerative fibrosis (Lev disease, Lenegre disease) most common etiology in elderly

›Progressive fibrocalcification of conduction system with aging

›No underlying structural heart disease required

›Age > 65 years is an independent risk factor for AV block

›Comorbidity burden

›Multiple comorbidities increase procedural risk

›Frailty assessment before pacemaker implantation

›CGA (comprehensive geriatric assessment) in complex cases

›Polypharmacy

›Review all AV-nodal blocking agents

›Drug interactions increasing digoxin toxicity risk (e.g., amiodarone, clarithromycin)

›Renal impairment

›Reduces digoxin and other drug clearance

›Dose adjustments for temporizing agents

›Atypical presentations

›Fatigue and functional decline rather than classic syncope

›Falls as presentation of hemodynamically significant pauses

›Cognitive decline from chronic low cardiac output

›Device considerations

›Pacemaker implantation remains indicated regardless of age

›Significant symptom burden and mortality benefit

›MRI-conditional devices preferred

›Elderly patients more likely to need future MRI

›Subcutaneous ICD generally avoided in very elderly

›Pacing function available with transvenous systems

›CRT consideration

›Benefits may persist even in elderly with reduced LVEF

Pediatrics

›Incidence and causes in children

›Mobitz II is rare in pediatric population

›Congenital complete heart block more common than acquired Mobitz II

›Most common pediatric causes

›Myocarditis (viral)

›Post-cardiac surgery (especially AV canal repair, VSD repair, AVSD)

›Lyme carditis in endemic areas

›Neuromuscular diseases

›Congenital heart disease

›Post-surgical AV block

›Incidence depends on procedure proximity to AV node

›Most post-surgical block resolves within 7-10 days

›Persistent block > 7-14 days warrants permanent pacemaker

›Presentation differences

›Infants: poor feeding, pallor, tachypnea rather than syncope

›Children: exercise intolerance, syncope with exertion

›Neonates: hydrops fetalis if very slow ventricular rate

›Treatment in children

›Transcutaneous pacing

›Pediatric pads for < 15 kg or < 8 years

›Adult pads acceptable for larger children

›Temporary transvenous pacing

›Fluoroscopy guidance preferred

›Smaller sheaths and leads based on patient size

›Permanent pacemaker indications

›Same threshold as adults: Mobitz II regardless of symptoms

›Lead selection based on patient size and anatomy

›Epicardial leads preferred in very small children or those with intracardiac shunts

›Pharmacologic doses

›Atropine 0.02 mg/kg IV (minimum 0.1 mg, maximum 0.5 mg per dose)

›May attempt once while recognizing likely ineffective for infranodal block

›Isoproterenol 0.01-0.5 mcg/kg/min IV infusion

›Epinephrine 0.01-0.1 mcg/kg/min IV infusion

10Background/b100

Epidemiology

›Incidence and prevalence

›Exact prevalence of Mobitz II is uncertain due to intermittent nature

›Estimated 1-2% of all AV blocks presenting to cardiology referral centers

›Age distribution

›Most common in older adults (> 60 years)

›Degenerative fibrosis predominates in this age group

›Younger patients more likely to have structural or infiltrative disease

›Risk factor epidemiology

›JAMA Network Open 2019 registry study (Kerola et al.)

›Chronic hypertension: OR ~1.8 for AV block

›Diabetes mellitus: OR ~1.5 for AV block

›Pre-existing BBB is strongest predictor of progression

›Sex distribution

›Slightly more common in males

›Female predominance in autoimmune etiologies

›Mortality and prognosis without treatment

›Significant risk of sudden cardiac death without pacemaker

›Progression to complete heart block unpredictable and often sudden

›Stokes-Adams attacks in up to 40-50% of untreated patients

›Post-pacemaker prognosis

›Survival determined primarily by underlying heart disease

›Conduction disease per se does not independently worsen prognosis after pacing

›ICD-10 coding

›Mobitz II: I44.1 (Second-degree atrioventricular block)

›With complete heart block: I44.2

›Cardiac pacemaker status: Z95.0

Pathophysiology

›Anatomic basis

›Infranodal location of block

›Below the AV node in the His bundle or bundle branches

›Contrasts with Mobitz I (Wenckebach) which is AV nodal

›Results in wide QRS in most cases (bundle branch disease)

›Narrow QRS Mobitz II

›Rare; intra-Hisian block within the His bundle itself

›QRS narrow because both bundle branches still conduct

›His bundle anatomy

›His bundle penetrates the central fibrous body

›Receives blood from AV nodal artery (RCA territory) and LAD

›Right bundle branch: LAD territory; left bundle: LAD + RCA

›Mechanism of block

›All-or-none failure of infranodal conduction

›Unlike Wenckebach which shows incremental fatigue of AV node

›Diseased His-Purkinje tissue conducts or fails completely

›Results in fixed PR before dropped beat (no incremental delay)

›Why PR is fixed

›AV node conducts normally; delay occurs below

›Conduction time above the block remains constant

›Only the infranodal segment fails intermittently

›Etiologic mechanisms

›Degenerative fibrosis (Lev and Lenegre disease)

›Progressive fibrocalcification replacing conduction tissue

›Most common cause in elderly without structural disease

›Ischemic

›Anterior MI: LAD supplies right bundle and anterior left bundle

›Inferior MI less commonly causes infranodal block

›Infiltrative

›Sarcoid granulomas replacing conduction tissue

›Amyloid fibrils disrupting conduction cell architecture

›Inflammatory/infectious

›Borrelia burgdorferi spirochetes causing local inflammation at AV junction

›Myocarditis with cellular infiltrate

›Neuromuscular

›Dystrophin gene mutations causing conduction cell loss

›Mitochondrial dysfunction in Kearns-Sayre syndrome

›Post-procedural

›Direct trauma to conduction tissue during cardiac surgery

›Inflammatory edema post-ablation or TAVR

Therapeutic Considerations

›Pacemaker evidence base

›ACC/AHA/HRS 2018 Bradycardia Guidelines (Kusumoto et al.)

›Class I: permanent pacing for acquired Mobitz II not due to reversible cause

›Based on observational data and expert consensus

›Level of Evidence C (expert opinion with supporting data)

›ACC/AHA/HRS 2012 Device Therapy Guidelines (Epstein et al.)

›Class I: asymptomatic Mobitz II with wide QRS

›Class IIa: asymptomatic Mobitz II with narrow QRS

›Evidence for CRT

›BLOCK HF trial: CRT superior to RV pacing in reduced LVEF

›Reduces pacing-induced cardiomyopathy risk

›His bundle and left bundle branch area pacing

›Physiologic pacing alternatives to RV apical pacing

›Recruit native His-Purkinje system

›Preserve mechanical synchrony

›His bundle pacing

›Success rate 80-90% in experienced centers

›Higher capture thresholds may affect battery longevity

›Left bundle branch area pacing

›Higher success rate than His bundle pacing

›Emerging as preferred physiologic pacing strategy

›Drug-induced AV block considerations

›Journal of Cardiovascular Electrophysiology 2025 (Sfairopoulos et al.)

›Drug-induced vs. drug-revealed AV block distinction

›~50% recurrence after drug discontinuation

›Supports early pacemaker in most cases

›ACC/AHA/HRS 2018: Class IIa for pacing without drug washout when medically necessary

›Monitoring technology

›Implantable loop recorder

›For suspected intermittent block not yet captured on surface ECG

›Provides years of continuous monitoring

›AHA 2017 ECG monitoring standards

›Category I conditions for continuous monitoring include high-degree AV block

›Defines monitoring duration requirements

11Patient Discharge Instructions/pdi46

copy discharge instructions

›Diagnosis and key information

›Diagnosed with Second-Degree AV Block (Mobitz Type II)

›A serious heart rhythm disorder where your heart skips beats due to a block in the electrical system

›This condition carries a significant risk of sudden progression to a complete block

›A pacemaker is the definitive treatment and is life-saving in most cases

›Activity restrictions before pacemaker

›Activity limitations

›No driving until pacemaker is implanted and confirmed functioning

›Avoid strenuous physical activity

›Avoid lifting > 5 kg

›Avoid operating heavy machinery

›Follow up urgently with your cardiologist or electrophysiologist if discharged before pacemaker

›After pacemaker implantation

›Wound care

›Keep incision clean and dry for 5-7 days

›Watch for redness, swelling, warmth, or discharge at site

›No submerging wound in water (bathing vs. showering restrictions per your team)

›Activity restrictions post-pacemaker

›Avoid raising implant-side arm above shoulder for 2-4 weeks

›Avoid heavy lifting on implant side for 4-6 weeks

›Most patients return to full activity within 4-6 weeks

›Device precautions

›Carry pacemaker identification card at all times

›Notify all healthcare providers of your pacemaker

›Security screening at airports: inform security, request hand wand

›Keep cell phones > 15 cm from device

›MRI: notify MRI team; MRI-conditional devices require specific protocol

12References/r49

Guidelines and key sources

›2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay

›Kusumoto FM, Schoenfeld MH, et al.

›Heart Rhythm. 2019

›Class I permanent pacing for acquired Mobitz II regardless of symptoms

›https://doi.org/10.1016/j.hrthm.2018.10.037

›2018 ACC/AHA/HRS Guideline Executive Summary

›Kusumoto FM, Schoenfeld MH, et al.

›Journal of the American College of Cardiology. 2019

›Temporizing pacing strategies and device selection guidance

›https://pubmed.ncbi.nlm.nih.gov/30412710

›2012 ACCF/AHA/HRS Focused Update for Device-Based Therapy

›Epstein AE, DiMarco JP, Ellenbogen KA, et al.

›Journal of the American College of Cardiology. 2013

›Class I and IIa indications by QRS width

›https://doi.org/10.1016/j.jacc.2012.11.007

›AHA Update to Practice Standards for ECG Monitoring

›Sandau KE, Funk M, Auerbach A, et al.

›Circulation. 2017

›Category I monitoring recommendation for high-degree AV block

›https://www.ahajournals.org/doi/10.1161/CIR.0000000000000527

›Centennial of Mobitz Type II second-degree AV block

›Barold SS, Herweg B.

›Journal of Cardiovascular Electrophysiology. 2024

›Historical and mechanistic review

›https://onlinelibrary.wiley.com/doi/10.1111/jce.16199

›Clinical Significance of Drug-Associated AV Block

›Sfairopoulos D, Bazoukis G, Sideris S, et al.

Evidence & Review