CHB with CAD is a common combination especially in the elderly.
Which will you Intervene first ? Is the AV block related to CAD ?
How to differentiate Ischemic from degenerative AV block ?
Differentiating is often difficult.Even coronary angiogram may not answer the query unless it is totally normal . For AV block to occur usually LCX / RCA lesion is required. LAD lesion in isolation are rare to cause CHB .
How often re-vascularisation reverses ischemic CHB ?
Logically you expect more reversals.In real world it rarely happens.
Therapeutic options in combined CAD and CHB
- PCI and pace maker in the same sitting .
- PCI first followed by pace-maker at a later date.
- Pace maker first followed by PCI at a later date if required.
- CABG and epicardial pacemaker ( best option In all critical TVD and CHB)
- Pace maker followed by CABG later
- Pacemaker followed by medical management (CHB with Insignificant CAD)
Can worsening of ischemia occur after pacemaker ?
Very much possible . Since the patient has been benefited by low heart rate in terms of MVO2 consumption .(Inserting a pacemaker is like sudden withdrawal of beta blocker !)
Rate adoptive pacing can confer chronotropic competence which may bring back the angina.So,what was a insignificant lesion can become hemodynamicaly relevant and may require angioplasty later.
*The above clinical issue is applicable for sinus node dysfunction and CAD as well.
Final message
There is no fixed rule in the management strategy in combined CHB and CAD .
Generally , electrical therapy should be given preference .Symptom guided approach may be practical.
In this scientific era , one may argue to deal both issues together by simultaneous PCI and pacemaker , still option 3 and 6 remain clear favorites !
If angina occurs even in baseline bradycardia it is obvious the obstructive CAD is significant and needs immediate fixing .
Finally , though it looks an attractive concept , It is very rare for CHB to get reverted by PCI or CABG.
Dr.S.Venkatesan MD 
Hello sir.just yesterday night got a patient 47yr m k/c dmt2 cad tvd multiple stents to lad , lcx (2007) lcx, rca(2013) lvef-60% (2007) –40% (2013).h/o 4 episodes syncope in last month.typical anginal pain at 9pm.ce to us around 1pm.ecg showed lbbb with chb/3°av block.last ecg 3months ago was rbbb.vitaly stable with reccurent chest pain.vr 40/m, ar 100/m.how would you approach.
Hi
I think you need to implant a PPM for him at the earliest
Venkatesan
I totally disagree. I worked as EP in 5 different high volume centres. The common practice is to treat the ischemia first then to implant a PM. The reason is simple, because we do not like to give Heparin after the device implant, as this may be complicated by pocket hematoma and hence you need to stop all the blood thinners even the aspirin!
Hi thank you for your comment.I do agree bleeding into the pocket is an issue.
But , currently DES is used for majority of PCI how do we with hold the dual antiplatelet agents early after PCI ?
Still , I would think ppm first would make a better choice in the majority .
Disputes are always welcome , they are the foundation stones for our learning
Thanks again
Venkatesan
Sir , I would strongly disagree with ur point on “Finally , though it looks an attractive concept , It is very rare for CHB to get reverted by PCI or CABG.”,I recently had a patient with CHB and IWMI , his CHB was reverted with rescue plasty to RCA ,
Thankyou for your input.
What I wanted to stress was “chronic Ischemic CHB” as a concept is an uncommon theme.
CHB with Acute inferior MI is well known to be transient and reversible with or witthout PCI or CABG.
Dr.S.Venkatesan.