Case for discussion

Complete heart block


Complete Heart Block

Complete heart block (or third-degree AV heart block)

A colleague showed me an unusual looking ECG on a patient with no cardiac symptoms. We asked a cardiologist for advice and he diagnosed Complete Heart Block (CHB). As the patient was well he was referred to cardiology clinic the following day for a pacemaker.

Complete heart block is the most serious type of AV heart block.  This is an abnormal heart rhythm (arrhythmia) that happens when there is a complete absence of electrical impulses (AV conduction) between the atria and ventricles.

Normally a back-up system keeps ventricles beating (junctional or ventricular escape rhythm), but the ventricles beat much slower than normal. This can affect the flow of blood to the body and brain and will cause symptoms of confusion, collapse, dizziness, breathlessness and tiredness.

Alternatively, the patient may suffer ventricular standstill leading to syncope (if self-terminating) or sudden cardiac death (if prolonged).

What causes complete heart block?

Most people with complete heart block have an underlying heart condition like coronary heart disease, cardiomyopathy or congenital heart disease.

It can also be caused by ageing of the electrical pathways in your heart (meaning you’re more likely to get it if you’re older), electrolyte imbalances, and some medicines (e.g. calcium-channel blockers, beta-blockers, digoxin)


The patient will have severe bradycardia (slow heartbeat) with independent atrial and ventricular rates, i.e. AV dissociation on ECG-see below.

Example of complete heart block

The atrial rate is approximately 100 bpm.

The ventricular rate is approximately 40 bpm.

The two rates are independent; there is no evidence that any of the atrial impulses are conducted to the ventricles.


Patients require urgent admission for cardiac monitoring, backup temporary pacing and usually insertion of a permanent pacemaker.



Case for discussion


ASCO: Alcohol Is Cancer Risk

First-time Statement

Nick Mulcahy
November 08, 2017
For the first time, the American Society of Clinical Oncology (ASCO) has formally stated that alcohol drinking is a risk factor for multiple malignancies and is potentially modifiable.
Furthermore, the organization believes their new “proactive stance” to minimize excessive alcohol intake has “important implications for cancer prevention.”
“Even modest use of alcohol may increase cancer risk, but the greatest risks are observed with heavy, long-term use,” write the ASCO statement authors, led by Noelle LoConte, MD, from the University of Wisconsin-Madison.
“Therefore, limiting alcohol intake is a means to prevent cancer,” Dr LoConte said in a statement. “The good news is that, just like people wear sunscreen to limit their risk of skin cancer, limiting alcohol intake is one more thing people can do to reduce their overall risk of developing cancer.”
ASCO’s statement, published online November 6 in the Journal of Clinical Oncology, has received widespread coverage in mainstream media.
“The message is not, ‘Don’t drink.’ It’s ‘If you want to reduce your cancer risk, drink less. And if you don’t drink, don’t start,'” Dr LoConte told The New York Times. “It’s different than tobacco, where we say, ‘Never smoke. Don’t start.’ This is a little more subtle.”
ASCO encourages oncologists to join their efforts: “Oncology providers can serve as community advisors and leaders and can help raise the awareness of alcohol as a cancer risk behavior.”
However, the organization also says there is “low physician knowledge of alcohol use and cancer risk.”
The general public also has low awareness. In a recent poll conducted by ASCO, 70% of Americans did not recognize drinking alcohol as a cancer risk factor, as reported by Medscape Medical News.
“People typically don’t associate drinking beer, wine, and hard liquor with increasing their risk of developing cancer in their lifetimes,” said ASCO President Bruce Johnson, MD. “However, the link between increased alcohol consumption and cancer has been firmly established.”
In its statement, ASCO notes that alcohol consumption is causally associated with oropharyngeal and laryngeal cancer, esophageal cancer, hepatocellular carcinoma, breast cancer, and colon cancer. However, alcohol may be a risk factor for other malignancies, including pancreatic and gastric cancers.
In total, ASCO estimates that 5% to 6% of new cancers and cancer deaths globally are directly attributable to alcohol.
A variety of causative mechanisms may be at play, depending on the particular cancer. Perhaps best known is the effect of alcohol on circulating estrogens, a pathway with relevance to breast cancer.
The American Heart Association, American Cancer Society, and US Department of Health and Human Services currently recommend that men limit intake to one to two drinks per day and women to one drink per day.
However, the ASCO statement authors observe that a meta-analysis found that one drink per day or less was still associated with some elevated risk for squamous cell carcinoma of the esophagus, oropharyngeal cancer, and breast cancer (Ann Oncol. 2013;24:301-308).
Defining risk-drinking can be “challenging,” say the statement authors, because the amount of ethanol in a drink varies depending on the type of alcohol (eg, beer, wine, or spirits) and its size.
Conflicting data about the impact of alcohol, especially red wine, on the heart is an “additional barrier” to addressing its related cancer risk. But recent research (Addiction. 2017;112:230-232) has cast doubt on those positive health claims studies, revealing multiple confounders, including frequent classification of former and occasional alcohol drinkers as nondrinkers, say the statement authors.
ASCO says that it joins a “growing number” of cancer care and public health organizations that support strategies designed to prevent high-risk alcohol consumption. Its statement offers evidence-based policy recommendations to reduce excessive alcohol consumption, as follows:
Provide alcohol screening and brief interventions in clinical settings.
Regulate alcohol outlet density.
Increase alcohol taxes and prices.
Maintain limits on days and hours of sale.
Enhance enforcement of laws prohibiting sales to minors.
Restrict youth exposure to advertising of alcoholic beverages.
Resist further privatization of retail alcohol sales in communities with current government control.
Include alcohol control strategies in comprehensive cancer control plans.
Support efforts to eliminate the use of “pinkwashing” to market alcoholic beverages (ie, discouraging alcoholic beverage companies from exploiting the color pink or pink ribbons to show a commitment to finding a cure for breast cancer given the evidence that alcohol consumption is linked to an increased risk for breast cancer).

Case for discussion


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