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Editorials |

Cilostazol : An “Intermittent Claudication” Remedy for the Management of Third-Degree AV Block

John E. Madias
Author and Funding Information

Affiliations: Elmhurst, NY
 ,  Dr. Madias is from the Division of Cardiology, Elmhurst Hospital Center, and the Mount Sinai School of Medicine, of the New York University.

Correspondence to: John E. Madias, MD, Professor of Medicine (Cardiology), Division of Cardiology, Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, NY 11373; e-mail: madiasj@nychhc.org



Chest. 2003;123(4):979-982. doi:10.1378/chest.123.4.979
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Third-degree AV block (3DAVB) of a persistent and not potentially reversible type associated with symptomatic bradycardia is a class I (beneficial, useful, and effective) indication to implant a permanent pacemaker (PP).12 Large experience with this procedure and phenomenal technological advances in the pacemaker generators, pacing leads, and programmability of these devices have established this mode of therapy as the “gold standard” to be implemented with almost no exception. Although such a recommendation is provided in the guidelines, it is also stated that alternative therapies can be considered if in the judgment of the physician this is deemed appropriate and/or the patient wishes not to undergo a device implantation. Occasionally, debilitation or incompetence of the patient, serious comorbidities, short expected survival, or involvement of the patients’ relatives lead to a decision not to implant a device. Also, for patients destined to undergo the procedure, some patient- or health system-dependent delays are often unavoidable (ie, the patient is anticoagulated or febrile, arrangements with the implanting physician or operating room had to be cancelled, or the implantation was unsuccessful). Thus, for such a seemingly straightforward therapeutic recommendation as the implantation of a PP for 3DAVB, it is sobering even for seasoned clinicians to experience the chain of events/actions often interspersed between diagnosis and implantation of the pacemaker. This latent period, up to a point, is useful for many reasons: (1) the diagnosis needs to be established, (2) the permanent or reversible (partially or completely) nature of the conduction abnormality should be determined, (3) the association of symptoms should be sought and managed, (4) the patient must be prepared, and (5) arrangements for PP implantation must be made. In the meantime, the patient can be observed and have drugs administered; if symptomatic, the patient can undergo a temporary transvenous ventricular pacemaker insertion3 or be paced via a transcutaneous noninvasive pacemaker.4 Most clinicians favor to have a pacing system in place for prophylaxis even in asymptomatic patients. Such devices can be either used for pacing at a faster than the intrinsic escape rate, or can be switched to a demand mode at a lower than the intrinsic patient’s rate to ensure protection if the escape rate falls further. The latter particularly applies to the transcutaneous pacemaking systems, since their activation is associated with some discomfort to the patients. Insertion of a temporary pacemaker requires expertise that should be acquired and maintained per issued guidelines.5 Complications of this procedure, which include local hematomas, pneumothorax, arrhythmias, and pericardial invasion, are decreasing with the more recent favor of the employment of the internal jugular venous route.56 Since some failures to pace with a temporary pacemaker occasionally occur, clinicians should start seeing with a more favoring eye the transcutaneous noninvasive pacing modalities; such systems were found to be tolerable in 89% of the cases, evoked effective ECG response in 78.4% of the patients, and were kept in place for periods up to 1 month in a clinical trial.4

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