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bundle and anterior and posterior fascicles of the left bundle Conduction block in each of these fascicles can be recognized on the surface ECG Although such conduction abnormalities are often seen in normal hearts, they are more commonly due to organic heart disease either an isolated process of fibrosis and calcification or more generalized myocardial disease Bifascicular block is present when two of these right bundle, left anterior and posterior hemibundle are involved Trifascicular block is defined as right bundle branch block with alternating left hemiblock, alternating right and left bundle branch block, or bifascicular block with documented prolonged infranodal conduction (long His-ventricular interval) The prognosis of intraventricular block is generally that of the underlying myocardial process Patients with no apparent heart disease have an overall survival rate similar to that of matched controls However, left bundle branch block but not right is associated with a higher risk of development of overt cardiac disease and cardiac mortality Even in bifascicular block, the incidence of occult complete heart block or progression to it is low, and pacing is not usually warranted In patients with symptoms (eg, syncope) consistent with heart block and intraventricular block, pacing should be reserved for those with documented concomitant complete heart block on monitoring or those with a very prolonged HV interval (> 90 ms) with no other cause for symptoms Even in the latter group, prophylactic pacing has not improved the prognosis significantly, probably because of the high incidence of ventricular arrhythmias in the same population

ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices: summary article J Am Coll Cardiol 2002 Nov 6;40(9):1703 19 [PMID: 12427427] Bryce M et al Evolving indications for permanent pacemakers Ann Intern Med 2001 Jun 19;134(12):1130 41 [PMID: 11412054] Faddis MN et al Pacing interventions for falls and syncope in the elderly Clin Geriatr Med 2002 May;18(2):279 94 [PMID: 12180248] Gregoratos G Indications and recommendations for pacemaker therapy Am Fam Physician 2005 Apr 15;71(8):1563 70 [PMID: 15864898] JAMA patient page Heart pacemakers JAMA 2001 Aug 15;286 (7):878 [PMID: 11519499] Trohman RG et al Cardiac pacing: the state of the art Lancet 2004 Nov 6 12;364(9446):1701 19 [PMID: 15530632] Vlietstra RE et al Choice of pacemakers in patients aged 75 years and older: ventricular pacing mode vs dual-chamber pacing mode Am J Geriatr Cardiol 2005 Jan Feb;14(1):35 8 [PMID: 15654152] Wong GC et al Single chamber ventricular compared with dual chamber pacing: a review Can J Cardiol 2002 Mar;18(3): 301 7 [PMID: 11907619]

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Prompt recovery without resuscitative measures Common clinical problem Accounts for 3% of all visits to the emergency department

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Thirty percent of the adult population will experience at least one episode of syncope It accounts for approximately 3% of emergency department visits Causes include cardiac abnormalities (either disturbances of rhythm or hemodynamics), vascular disorders, or neurologic processes Syncope is more likely to occur in patients with known heart disease, older men, and young women (who are prone to vasovagal episodes) In many patients with recurrent syncope or near syncope, arrhythmias are not the cause This is particularly true when the patient has no evidence of associated heart disease by history, examination, standard ECG, or noninvasive testing Syncope may be neurocardiogenic in origin, mediated by excessive vagal stimulation, or an imbalance between sympathetic and parasympathetic autonomic activity With assumption of upright posture, there is venous pooling in the lower limbs However, instead of the normal response, which consists of an increase in heart rate and vasoconstriction, a sympathetically mediated increase in myocardial contractility activates mechanoreceptors that trigger reflex bradycardia and vasodilation Autonomic testing can be an important component of the evaluation in these individuals and, if performed, should usually precede invasive electrophysiologic procedures A specific cause of syncope is identified in about 50% of cases during the initial evaluation The prognosis is relatively favorable except when accompanying cardiac disease is present Vasomotor syncope may be due to excessive vagal tone or impaired reflex control of the peripheral circulation The most frequent type of vasodepressor syncope is vasovagal hypotension or the common faint, which is often initiated by a stressful, painful, or claustrophobic experience, especially in young women Enhanced vagal tone with resulting hypotension is the cause of syncope in carotid sinus hypersensitivity and postmicturition syncope; vagal-induced sinus bradycardia, sinus arrest, and AV block are common accompaniments and may themselves be the cause of syncope Orthostatic (postural) hypotension is another common cause of vasomotor syncope, especially in the elderly; in diabetics or other patients with autonomic neuropathy; in patients with blood loss or hypovolemia; and in patients taking vasodilators, diuretics, and adrenergic-blocking drugs In addition, a syndrome of chronic idiopathic orthostatic hypotension exists primarily in older men In most of these conditions, the normal vasoconstrictive response to assuming upright posture, which compensates for the abrupt decrease in venous return, is impaired Cardiogenic syncope can occur on a mechanical or arrhythmic basis There is usually no prodrome; thus, injury secondary to falling is common Mechanical problems that can cause syncope include aortic stenosis (where syncope may occur from autonomic reflex abnormalities or ventricular.

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