Q. My pulse rate suddenly reduces to 40 bpm with dizziness. Is this a sign of heart block?

Answered by
Dr. Sagar Ramesh Makode
and medically reviewed by Dr. Vinodhini. J
This is a premium question & answer published on Oct 08, 2020

Hi doctor,

I am an 80-year-old woman with a little history of hypertension but without any other significant health issues. I am not on any medication at all. My blood pressure historically has been in a band of 120/80 up to 140/100 or so. My pulse is generally 80-95 bpm. I usually measure my blood pressure and pulse once or twice a day to monitor it. In the last week, I noticed my pulse fell significantly to around 40-50 bpm while doing this. It stayed that well for some hours or overnight. However, lately, I had back up to 80-90 and has remained stable at that level in recent days. I had an ECG done, which showed nothing, and a Holter monitor test (results attached).

My questions are, is what I am describing showing heart block? If yes, then what sort of heart block is it? Can a heart block be intermittent i.e., pulse fell to 40 but then recovered to 80? 90 bpm and has stabilized at that level. If it has stabilized, can I leave it alone? Is the treatment required for this? I prefer to avoid pacemaker or other surgeries.



Welcome to icliniq.com.

Yes, it is a heart block, and it is a 2:1 AV (arteriovenous) block. Block can be intermittent, present at sometimes, and recover at other times. This certainly requires treatment as it can be life-threatening or may lead to syncope if the heart rate drops further down. I guess you are not on any medications like beta-blockers, which may cause this. Also, we have to rule out the possibility of hypothyroidism and electrolyte imbalance. So you should undergo a thyroid profile, renal function test with electrolytes. Also, echo should be done as a part of an evaluation to rule out coronary artery disease.

Overall this appears to be an age-related heart block, and a pacemaker is a treatment of choice for this if we do not find any reversible cause. Medications are not reliable for this issue. So most probably, a pacemaker will be necessary. And it is a not major surgery and done under local anesthesia only.

I hope this helps.

Thank you doctor,

Is there a reason that I would do an angiogram over an echocardiogram?



Welcome back to icliniq.com.

Echo will always be done to see heart function or to find any evidence of coronary artery disease. If echo shows any evidence of blockages or even otherwise, an angiogram may be performed before the pacemaker to rule out the possibility of blockages. Because if there are blockages in the arteries, then treating them might cure heart block, avoiding a pacemaker's need. So angiogram may be performed before the pacemaker.

Thank you doctor,

If the echocardiogram is normal, then is there need for an angiogram? Is there still a need for a pacemaker?



Welcome back to icliniq.com.

If echo is normal, then still angiogram might be performed as a screening procedure, to be sure. This case depends on the doctor's assessment or hospital protocol, and some doctor may just perform stress echo or CT coronary angiography as a screening. So here, angiogram may or may not be done. But then a pacemaker is a must.

However, if an echo is abnormal, then an angiogram is a must, and if it shows blockages, then those blockages will be open with angioplasties or bypass depending upon the extent of blockages. Because opening of blockages will cure heart block and avoid pacemaker surgery.

So, in a nutshell, you will either need a pacemaker or some coronary procedure.

Thank you doctor,

Is angiogram risky procedure? Can it cause a heart attack? After the angiogram, will I need to take Aspirin or blood thinners temporarily or permanently? Does this depend on whether the angiogram involves angioplasty or stenting as well? Or does a basic angiogram require Aspirin afterward forever?



Welcome back to icliniq.com.

No, angiogram are relatively safe and does not carry significant risks. It is extremely rare to get a heart attack during an angiogram. Since it is a diagnostic test, you do not need to take any blood thinners or Aspirin lifelong unless there is a disease within vessels or you undergo stenting. So basic angiogram does not need anything afterward.

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