Sfairopoulos Dimitrios, Bazoukis George, Sideris Skevos, Fragakis Nikolaos, Letsas Konstantinos, Zekios Konstantinos, Liu Tong, Korantzopoulos Panagiotis
First Department of Cardiology, University of Ioannina Medical School, Ioannina, Greece.
Department of Cardiology, Larnaca General Hospital, State Health Services Organization, Larnaca, Cyprus.
J Cardiovasc Electrophysiol. 2025 Jul;36(7):1643-1653. doi: 10.1111/jce.16697. Epub 2025 Apr 28.
The development of advanced atrioventricular block (AVB) in patients on bradycardic and/or antiarrhythmic therapy (drug-related AVB) represents a clinical challenge, raising the question of whether the AVB is directly caused by these agents (drug-induced AVB) or if the offending drugs exacerbate an underlying conduction system disease. Traditionally, β-blockers, non-dihydropyridine calcium channel blockers, class Ic/III antiarrhythmics, and digoxin have been considered reversible causes of advanced AVB. However, recent evidence shows a weak cause-and-effect relationship between these drugs and AVB in the elderly, along with high recurrence rates of AVB despite initial resolution after drug discontinuation. This may also apply to patients on high doses of these medications, drug combinations, or with additional reversible factors such as hyperkalemia. Despite these considerations, the European Guidelines do not suggest permanent pacing for AVB due to transient causes that are correctable, including bradycardic/antiarrhythmic drug therapy. On the other hand, the American Guidelines recommend permanent pacing for selected patients with symptomatic second- or third-degree AVB who are on stable, necessary antiarrhythmic or β-blocker treatment, without waiting for drug washout or reversibility. Notably, an accumulating body of evidence indicates that true drug-induced AVB is rare, while recurrence rates are high. Therefore, early permanent pacing should be recommended, especially for frail elderly patients. Moreover, in patients with drug-related AVB and atrial tachyarrhythmias, adopting an early permanent pacing approach seems prudent when bradycardic and/or antiarrhythmic treatment is necessary. Finally, delays in permanent pacing are not justified when temporary pacing is needed, given the increased associated risks in such cases.
接受缓慢性和/或抗心律失常治疗的患者出现进展性房室传导阻滞（AVB）（药物相关性AVB）是一项临床挑战，这引发了一个问题，即AVB是由这些药物直接引起的（药物性AVB），还是有害药物使潜在的传导系统疾病恶化。传统上，β受体阻滞剂、非二氢吡啶类钙通道阻滞剂、Ic/III类抗心律失常药物和地高辛被认为是进展性AVB的可逆性病因。然而，最近的证据表明，在老年人中，这些药物与AVB之间的因果关系较弱，而且尽管停药后AVB最初得到缓解，但复发率较高。这也可能适用于服用高剂量这些药物、联合用药或存在其他可逆因素（如高钾血症）的患者。尽管有这些考虑因素，但欧洲指南并不建议对因可纠正的短暂性病因（包括缓慢性/抗心律失常药物治疗）导致的AVB进行永久性起搏。另一方面，美国指南建议对接受稳定、必要的抗心律失常或β受体阻滞剂治疗的有症状的二度或三度AVB患者进行永久性起搏，而不必等待药物洗脱或可逆性。值得注意的是，越来越多的证据表明，真正的药物性AVB很少见，而复发率很高。因此，应建议早期进行永久性起搏，尤其是对于体弱的老年患者。此外，对于有药物相关性AVB和房性快速性心律失常的患者，当需要进行缓慢性和/或抗心律失常治疗时，采用早期永久性起搏方法似乎是谨慎的。最后，在需要临时起搏的情况下，永久性起搏的延迟是不合理的，因为这种情况下相关风险会增加。
