/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/cpg/,/clinical/cckm-tools/content/cpg/cardiovascular/,

/clinical/cckm-tools/content/cpg/cardiovascular/name-114660-en.cckm

20170386

page

100

UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Clinical Practice Guidelines,Cardiovascular

Management of Patients Undergoing Endoscopic Procedures with Heart Block - Adult - Ambulatory

Management of Patients Undergoing Endoscopic Procedures with Heart Block - Adult - Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Cardiovascular


1



Management of Patients Undergoing
Endoscopic Procedure with Suspected
or Confirmed Heart Block – Adult –
Ambulatory
Clinical Practice Guideline


Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ........................................................................................................................................... 3
SCOPE .................................................................................................................................................................... 3
METHODOLOGY ..................................................................................................................................................... 4
DEFINITIONS .......................................................................................................................................................... 4
INTRODUCTION ..................................................................................................................................................... 5
RECOMMENDATIONS ............................................................................................................................................ 5
UW HEALTH IMPLEMENTATION ............................................................................................................................. 7
APPENDIX A. EVIDENCE GRADING SCHEME(S) ....................................................................................................... 8
REFERENCES ......................................................................................................................................................... 10






Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

2


Contact for Content:
Name: Deepak Gopal, MD - Gastroenterology
Phone Number: (608) 263-7322
Email Address: dvg@medicine.wisc.edu

Contact for Changes:
Name: Lindsey Spencer – Center for Clinical Knowledge Management
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org

Coordinating Team Members:
Annie Kelly, MD- Medicine- Cardiology
Anne O’Connor, MD- Medicine- Cardiology
Joel Johnson, MD- Anesthesiology
Jeffrey Lee, MD- Anesthesiology
Anne Rikkers, RN- Medicine- Gastroenterology
Jane Hartman, RN- Digestive Health Center Admin
Katherine Le, PharmD- Center for Clinical Knowledge Management (CCKM)

Review Individuals/Bodies:
Carin Endres, PharmD- Drug Policy
Michael Field, MD- Cardiology

Committee Approvals/Dates:
DHC Executive Committee (03/01/2017)
Clinical Knowledge Management (CKM) Council (Last Periodic Review: 03/23/2017)


Release Date: March 2017 | Next Review Date: March 2020






















Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

3


Executive Summary
Guideline Overview
This guideline was developed to assist clinicians in determining whether or not to perform an
endoscopic procedure for a patient with a newly suspected atrioventricular (AV) block.

Key Practice Recommendations
1. If a patient is diagnosed with a 1st degree AV block or 2nd degree type I AV block and is
hemodynamically stable, the endoscopic procedure may be performed. A first-degree heart
block is typically not an indication for hospital admission and no specific treatment is
generally required.1 A second degree type I AV block usually has a benign cause and
treatment is unnecessary in most cases as well.2 (UW Health GRADE Very low quality of
evidence, weak/conditional recommendation)
2. If the patient is diagnosed with a 2nd degree type II AV block or 3rd degree AV block, it is
recommended to cancel the procedure and treat as clinically indicated. (UW Health GRADE
Very low quality of evidence, weak/conditional recommendation)
3. If the AV block occurs during a procedure and resolves spontaneously within seconds or
minutes, the physician may consider completing the procedure. (UW Health GRADE Very low
quality of evidence, weak/conditional recommendation)
4. If the AV block occurs as a narrow QRS complex or prolonged PR interval with significant
decreased in blood pressure or heart rate, the provider may consider giving atropine as it
reduces AV block due to hypervagotonia.3,4 (UW Health GRADE Low quality of evidence,
weak/conditional recommendation)
5. If AV block occurs more than once after initial resolution, consider aborting the procedure.
(UW Health GRADE Very low quality of evidence, strong recommendation)
6. If AV block occurs as multiple P waves in a row or a wide QRS complex, consider aborting
the procedure as these are indications that a 2nd degree type II AV block or worse is
occurring. (UW Health GRADE Moderate quality of evidence, strong recommendation)

Companion Documents
Adult Endoscopy Patients Heart Block Algorithm
Scope
Disease/Condition(s): Heart block

Clinical Specialty: Gastroenterology, Cardiology, Anesthesiology

Intended Users: Physicians, Advanced Practice Providers, Nurses

Objective(s): To determine if an endoscopic procedure should be done in a patient with a new
AV block who do not have a pacemaker

Target Population: Adult patients who present to the Digestive Health Center or Ambulatory
Procedure Center for an endoscopic procedure with a suspected new AV block based off of pre-
procedural bedside monitoring.

Interventions and Practices Considered:
1. Cancellation of the procedure
2. Pharmacotherapy for heart block
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

4



Major Outcomes Considered:
1. None identified
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.

Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).

Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.

Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1 in Appendix A).

Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.

Recognition of Potential Health Care Disparities: None identified.
Definitions
First Degree AV block is a prolongation of the PR interval on an electrocardiogram (ECG). In a
first-degree AV block, each P wave is followed by a QRS complex with a PR interval that
exceeds 200 milliseconds.5

Second Degree Type I AV block or Mobitz type I AV block occurs when conduction of the atrial
impulses to the ventricles is intermittently blocked. It is characterized by a progressive increase
in PR interval prior to a blocked non conducted beat/QRS complex. After the dropped QRS, AV
conduction recovers resulting in a normal PR interval and a progressive increase in PR interval
begins again.1

Second Degree AV block Type II or Mobitz type II AV block is due to intermittent failure of
conduction of atrial impulses to the ventricles. It is characterized by fixed PR intervals before
and after blocked beats and may be associated with a wide QPRS morphology.6 Advanced
second-degree block is the block of two or more consecutive P waves.1

Third Degree AV block happens when there is no conduction of impulses from the atria to the
ventricles.5
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

5


Introduction
Atrioventricular blocks are a disruption in the conduction of the atrial impulse to the heart
ventricle. Transient AV block can occur in about 4% of women and 6% of men. This number
decreases in the normal older adult population, with Type I second degree AV block observed in
about 1% of the population.7 Vagally mediated AV block can occur in otherwise healthy
individuals and is generally benign, however it should be differentiated from true type II Mobitz
block which requires immediate medical attention.1

Given the vagus nerve’s relationship to the abdomen and parasympathetic nervous system and
sedatives’ effect on the respiratory system, it is critical to be attentive to any suspected heart
block in a patient undergoing a digestive health procedure. This guideline is meant to aid
clinicians in determining how to proceed in a patient undergoing an endoscopic procedure with
a newly suspected heart block.
Recommendations
Baseline evaluation
1. Patients with a suspected new heart block based off of pre-procedural monitoring should
have vital signs checked and be assessed for related symptoms. A brief chart review
should also be conducted to check for any previously documented cardiac history (e.g. prior
ECGs for comparison) or treatment.
2. Patient should be set up with telemetry for baseline.
3. A 12-lead ECG should be done to assess current heart rhythm in patient.

Diagnosis of AV heart block
1. If patient is diagnosed with a 1st degree AV block or 2nd degree type I AV block and is
hemodynamically stable, the endoscopic procedure may be done. A first-degree heart block
is typically not an indication for hospital admission and no specific treatment is generally
required.1,8 A second degree type I AV block usually has a benign cause and treatment is
unnecessary in most cases as well.2 (UW Health GRADE Very low quality of evidence,
weak/conditional recommendation)
2. If patient is diagnosed with a 1st degree heart block and with an especially long PR interval
(> 300 milliseconds), the endoscopic procedure may be done. (UW Health GRADE Very low
quality of evidence, weak/conditional recommendation)
3. If the patient is diagnosed with a 2nd degree type II AV block or 3rd degree AV block, it is
recommended to cancel the procedure.
a. For 2nd degree type II AV block, it is recommended to consider admission after
consultation with cardiology. (UW Health GRADE Very low quality of evidence, strong
recommendation)
b. For 3rd degree AV block, it is recommended to treat the patient as clinically indicated.
(UW Health GRADE Very low quality of evidence, strong recommendation)
c. For symptomatic high-degree AV block, provide transcutaneous pacing without
delay. Symptoms may include: acute altered mental status, ongoing severe
ischemic chest pain, congestive heart failure, hypotension or other signs of shock.9
(UW Health GRADE Very low quality of evidence, strong recommendation)


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

6


Intraoperative Heart Block
1. If the AV block occurs during a procedure and resolves spontaneously within seconds or
minutes, the physician may consider completing the procedure. (UW Health GRADE Very low
quality of evidence, weak/conditional recommendation)
2. If the AV block occurs as a narrow QRS complex or prolonged PR interval with significant
decreased in blood pressure or heart rate, the provider may consider giving atropine as it
reduces AV block due to hypervagotonia.3,4 Atropine may be given 0.5mg-1mg every 3-5
minutes, up to a maximum of 3 mg total. (UW Health GRADE Low quality of evidence,
weak/conditional recommendation)
3. If AV block occurs more than once after initial resolution, consider aborting the procedure.
(UW Health GRADE Very low quality of evidence, strong recommendation)
4. If AV block occurs as multiple P waves in a row or a wide QRS complex, consider aborting
the procedure as these are indications that a 2nd degree type II AV block or worse is
occurring. (UW Health GRADE Moderate quality of evidence, strong recommendation)

Follow-Up
1. Patients with a 1st degree heart block with an especially long PR interval (> 300
milliseconds) or 2nd degree type I AV block should follow-up with primary care provider or
cardiologist (if established cardiology patient.) (UW Health GRADE Very low quality of evidence,
weak/conditional recommendation) Communication should be made via re: message to primary
care staff with documentation on the Problem List.
2. For all patients with newly diagnosed AV block, the physician should consider specifically
documenting the block occurred in the patient’s health record.
3. Patients with newly diagnosed AV block who do not use the UW Health system for standard
medical care may be provided a copy of his or her ECG for referral/consultation purposes.
(UW Health GRADE Very low quality of evidence, weak/conditional recommendation)

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

7


UW Health Implementation
Potential Benefits:
1. Patient safety

Potential Harms:
1. Patient mortality
2. Overutilization of cardiology consultation services
3. Overutilization of Emergency Department visits

Pertinent UW Health Policies & Procedures
None identified.

Patient Resources
1. Health Information- Heart Block
2. Health Information- Heart Rate Problems: Should I Get a Pacemaker?
3. Health Information- Heart Rhythm Problems: Symptoms

Guideline Metrics
1. Number of gastroenterology patients referred to same-day cardiology clinic

Implementation Plan/Clinical Tools
1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the
guideline recommendations will be reviewed for consistency and modified as appropriate.


Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

8


Appendix A. Evidence Grading Scheme(s)

Figure 1. GRADE Methodology adapted by UW Health


GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations For or Against Practice
Strong The net benefit of the treatment is clear, patient values and circumstances
are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

Patient Presents for Endoscopic Procedure
Bedside monitor shows potential NEW heart block
Algorithm for Patients Undergoing an Endoscopy with Heart Block- Adult
Additional Details
A.
RN should obtain vital signs,
assess for related symptoms
and known history of
arrhythmia.
Perform brief chart review for
any previously documented
cardiac history (i.e., prior
EKGs for comparison) or
treatment.
B.
In general it is ok to
proceed with procedural
sedation in patients with 1
st
degree heart block and 2
nd
degree (type I) and have
patients under endoscopic
procedure.
However, if the physician
feels otherwise, he/she may
consult cardiologist on call.
C.
For symptomatic high-
degree atrioventricular (AV)
block, follow ACLS protocols.
Symptoms may include: acute
altered mental status,
ongoing severe ischemic
chest pain, congestive heart
failure, hypotension, or other
signs of shock.
D.
If unsure of rhythm, review
case and ECG with the on call
Cardiologists. (This could be
done via the UW Access
Center if admission is likely).
For full reference information,
please refer to Patient
Undergoing Endoscopic
Procedure with Suspected Heart
Block Clinical Practice Guideline
Brief Chart Review & Medical Screening Exam
Telemetry for baseline
A
Obtain 12-lead ECG to assess current heart rhythm
Perform
Procedure
1
st
degree
AV block?
B
2
nd
degree
(type I)
AV block?
B
NO
NO
YES
YES
Notify Primary Care Provider
(or Cardiology if established)
via re: message when 1
st

degree AV block with long PR
interval (> 300 msec) or 2
nd

degree (type 1) AV block.
Intraoperative Heart Block
Heart block occurs… What to Do
…and spontaneously resolves within seconds
or minutes or resolves with change in patient’s
position
Consider continuing with procedure
…as narrow QRS complex or prolonged PR
interval with significant decrease in BP or HR
Consider giving atropine
Dosing: Atropine IV 0.5-1 mg, may repeat
every 3-5 minutes, max of 3mg total
If no resolution after 2
nd
dose, consider
aborting procedure
…occurs more than once after initial resolution Consider aborting procedure
…multiple P waves in a row or a wide QRS
complex
Consider aborting procedure
3
rd
degree AV block
2
nd
degree (type II) AV block
2:1 AV block
Cancel Procedure
C,D
May warrant inpatient evaluation. Send to Emergency
Department or consider direct admission after phone
consultation with on call Cardiologist
(CARDIOLOGY STAFF WARD (CCU)).
Consider documenting
new heart block in note
and adding to Health
Link Problem List.
If non-UW Health
patient, give the patient
a copy of their ECG.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

10


References
1. Cameron P. Textbook of Adult Emergency Medicine Expert Consult - Online and Print.
4th ed. London : Elsevier Health Sciences UK, 2014.; 2014.
2. EA A, Niebauer, J. Cardiology Explained. In: London: Remedica; 2004:
https://www.ncbi.nlm.nih.gov/books/NBK2219/. Accessed February 9, 2017.
3. Ferri FF. Ferri's Clinical Advisor 2017 5 Books in 1. : Elsevier Health Sciences,
2016.; 2016.
4. Ganansia MF, Francois TP, Ormezzano X, Pinaud ML, Lepage JY. Atrioventricular
Mobitz I block during propofol anesthesia for laparoscopic tubal ligation. Anesth Analg.
1989;69(4):524-525.
5. Crawford MH. Cardiology. 3rd ed. London : Elsevier Health Sciences UK, 2009.; 2009.
6. Ferri FF. Ferri's Clinical Advisor 2017 5 Books in 1. : Elsevier Health Sciences, 2016.;
2016.
7. Saksena S. Electrophysiological Disorders of the Heart Expert Consult. 2nd ed. London :
Elsevier Health Sciences, 2011.; 2011.
8. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on
perioperative cardiovascular evaluation and management of patients undergoing
noncardiac surgery: a report of the American College of Cardiology/American Heart
Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;64(22):e77-137.
9. Part 7.3: Management of Symptomatic Bradycardia and Tachycardia. Circulation.
2005;112(24 suppl):IV-67.

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org