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Fig. 23. This patient with anterolateral MI developed RBBB and LPFB. A temporary pacemaker was placed. Because of intermittent second-degree A-V block, a permanent pacemaker was implanted.

Fig. 24. This 75-yr-old male with anteroseptal MI developed RBBB, LAFB, and first-degree A-V block—so-called trifascicular block. Because the patient had received thrombolytic therapy, transcutaneous pacing pads were placed. No pacing was required over the next 72 h. Sustained monomorphic VT occurred 5 d post-MI, and a dual-chamber ICD was placed.

Fig. 24. This 75-yr-old male with anteroseptal MI developed RBBB, LAFB, and first-degree A-V block—so-called trifascicular block. Because the patient had received thrombolytic therapy, transcutaneous pacing pads were placed. No pacing was required over the next 72 h. Sustained monomorphic VT occurred 5 d post-MI, and a dual-chamber ICD was placed.

Indications for Permanent Pacemaker After MI

Clinical trial data are few regarding indications for permanent pacemaker implantation in patients with AMI (145). A retrospective, nonrandomized multicenter study (140) suggested a better outcome when permanent pacemakers were placed in patients who have transient high-grade AV block and permanent BBB. The recently updated ACC/ AHA task force AMI guidelines discuss indications for permanent pacing after AMI in detail (2). Any patient with persistent, symptomatic sinus bradycardia or AV block should receive a permanent pacemaker (or ICD, if indicated) prior to discharge. The same is true of any patient with permanent second- or third-degree block at the level of the His-Purkinje system, as well as patients with permanent BBB and transient Mobitz II second-degree AV block or third-degree AV block. The utility of permanent pacing in asymptomatic patients with persistent second- or third-degree block at the AV nodal level (following IMI) has not been demonstrated, although there is frequently a reluctance to discharge patients in CHB without permanent pacemakers. In general, patients with evidence of tenuous infranodal conduction will probably benefit from permanent pacing. A limited electrophysiologic study (EPS) is reasonable if the level of conduction block is unclear from the clinical scenario.

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