Risk stratification

The aim of risk stratification in the ED is to identify those patients who are at high risk of developing complete heart block and who require admission for cardiology review and permanent pacemaker insertion (PPM).

Patients with isolated, asymptomatic bifascicular block are usually low risk.

Patients who present with bifascicular block and pre-syncope or syncope may be experiencing periods of complete heart block, so require admission. The ESC and ACC/HRS recognise bifascicular block as a high-risk ECG feature for cardiac syncope.

One study9 identified the following four independent risk factors for patients requiring PPM insertion:

  • Presence of syncope or pre-syncope       
  • QRS greater than 140 ms
  • Renal failure
  • HV interval greater than 64 ms

NB HV is a measurement derived from electrophysiological studies (EPS) and not relevant to risk assessment in the ED.

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