Electrocardiographic findings of methanol toxicity: a cross-sectional study of 356 cases in Iran.

BACKGROUND: Methanol is widely used in industry; however, methanol poisoning is not common. In this regard, a number of outbreaks have been recently reported due to inappropriate processing of alcoholic beverages. Shiraz, a city located in the southern part of Iran, faced one of such outbreaks in 2020 during COVID-19 pandemic. There is no sufficient literature on the electrocardiographic findings in methanol toxicity. This study aimed to address this gap in the literature. METHOD: A total of 356 cases with methanol toxicity referred to Shiraz University of Medical Science Tertiary Hospitals (Faghihi and Namazi) in March and April, 2020. The clinical findings of blindness and impaired level of consciousness, lab data such as arterial blood gas, electrolytes, and creatinine, and the most common findings from ECGs were collected. RESULTS: The most common ECG findings were J point elevation (68.8%), presence of U wave (59.2%), QTc prolongation (53.2% in males and 28.6% in females), and fragmented QRS (33.7%). An outstanding finding in this study was the presence of myocardial infarction in 5.3% of the cases. This finding, to the best of our knowledge, has only been reported in a few case reports. Brugada pattern (8.1%) and Osborn wave (3.7%) were the other interesting findings. In multivariate analysis, when confounding factors were adjusted, myocardial infarction, atrioventricular conduction disturbances, sinus tachycardia, and the prolonged QTC > 500 msecond were four independent factors correlated with methanol toxicity severity measured with arterial blood PH on arterial blood gas measurements, with odds ratios of 12.82, 4.46, 2.32 and 3.15 (P < 0.05 for all), respectively. CONCLUSION: Electrocardiographic variations during methanol intoxication are remarkable and well-correlated with poisoning severity. Myocardial infarction was an egregious and yet a common concerning finding in this sample, which need to be ruled out in methanol toxicity.

Discordant immune complete heart block and growth restriction in dichorionic twin pregnancy with permanent pacemaker implantation of an 1140 g neonate.

Fetal atrioventricular block is a rare pathology, mostly due to placental transmission of maternal SSA/Ro and SSB/La antibodies, and can lead to severe fetal or neonatal outcomes. We report a case of dichorionic, diamniotic twin pregnancy, with maternal SSA/Ro antibodies. Isolated complete atrioventricular block was diagnosed at 23 weeks in one fetus (Twin A), while the second fetus (Twin B) remained in normal sinus rhythm. Severe asymmetric intrauterine growth restriction occurred in Twin A. Delivery was by caesarean section at 32 + 2 weeks. Neonatal permanent pacemaker was inserted on the first day after birth in 1140 g neonate. Discordant heart block in twin pregnancy has already been reported in a few dichorionic pregnancies, but the pathway of discordant disease expression remains unclear. Extraction decision is a dilemma between cardiac failure prevention and prematurity associated twin morbidity. This case shows a successful pacing in a very low birth weight neonate.

Trypanosoma cruzi Neurotrophic Factor Facilitates Cardiac Repair in a Mouse Model of Chronic Chagas Disease.

Most patients acutely infected with Trypanosoma cruzi undergo short-term structural and functional cardiac alterations that heal without sequelae. By contrast, in patients whose disease progresses to chronic infection, irreversible degenerative chronic Chagas cardiomyopathy (CCC) may develop. To account for the contrast between cardiac regeneration in high-parasitism acute infection and progressive cardiomyopathy in low-parasitism CCC, we hypothesized that T. cruzi expresses repair factors that directly facilitate cardiac regeneration. We investigated, as one such repair factor, the T. cruzi parasite-derived neurotrophic factor (PDNF), known to trigger survival of cardiac myocytes and fibroblasts and upregulate chemokine chemokine C-C motif ligand 2, which promotes migration of regenerative cardiac progenitor cells (CPCs). Using in vivo and in vitro models of Chagas disease, we tested whether T. cruzi PDNF promotes cardiac repair. Quantitative PCR and flow cytometry of heart tissue revealed that stem-cell antigen-1 (Sca-1+) CPCs expand in acute infection in parallel to parasitism. Recombinant PDNF induced survival and expansion of ex vivo CPCs, and intravenous administration of PDNF into naïve mice upregulated mRNA of cardiac stem-cell marker Sca-1. Furthermore, in CCC mice, a 3-week intravenous administration of PDNF protocol induced CPC expansion and reversed left ventricular T-cell accumulation and cardiac remodeling including fibrosis. Compared with CCC vehicle-treated mice, which developed severe atrioventricular block, PDNF-treated mice exhibited reduced frequency and severity of conduction abnormalities. Our findings are in support of the novel concept that T. cruzi uses PDNF to promote mutually beneficial cardiac repair in Chagas disease. This could indicate a possible path to prevention or treatment of CCC.

Investigation of an N-Terminal Prohormone of Brain Natriuretic Peptide Point-of-Care ELISA in Clinically Normal Cats and Cats With Cardiac Disease.

BACKGROUND: N-terminal prohormone of brain natriuretic peptide (NT-proBNP) concentrations may be increased in cats with various cardiac disorders. The point-of-care (POC) ELISA assay uses the same biologic reagents as the quantitative NT-proBNP ELISA. Previous studies have evaluated the sensitivity and specificity of the POC ELISA in cats with cardiac disease. OBJECTIVES: To prospectively evaluate the diagnostic utility of the POC ELISA in a select population of cats. ANIMALS: Thirty-eight client-owned cats presented to the University of Florida Cardiology Service for cardiac evaluation. Fifteen apparently healthy cats recruited as part of another study. METHODS: Physical examination and echocardiography were performed in all cats. The POC ELISA was assessed visually as either positive or negative by a reader blinded to the echocardiographic findings, and results were analyzed relative to quantitative assay results. RESULTS: Twenty-six cats were diagnosed with underlying cardiac disease, and 27 cats were considered free of cardiac disease. Cats with cardiac disease included: 21 with hypertrophic cardiomyopathy, 2 with unclassified cardiomyopathy, 2 with restrictive cardiomyopathy, and 1 with 3rd degree atrioventricular (AV) block. The POC ELISA differentiated cats with cardiac disease with a sensitivity of 65.4% and specificity of 100%. CONCLUSIONS AND CLINICAL IMPORTANCE: The POC NT-proBNP ELISA performed moderately well in a selected population of cats. A negative test result cannot exclude the presence of underlying cardiac disease, and a positive test result indicates that cardiac disease likely is present, but further diagnostic investigation would be indicated for a definitive diagnosis.

Follow-up of troponin I concentration in dogs with atrioventricular block and dual-chamber pacing in a case-matched study.

BACKGROUND: Increased cardiac troponin I (cTnI) concentration has been reported in dogs with atrioventricular (AV) block before and shortly following pacemaker implantation. The role of AV dyssynchrony, age, or concurrent cardiac disease on cTnI concentration remains unknown. OBJECTIVES: To investigate change in cTnI concentration following dual-chamber pacemaker implantation on short- and long-term follow-up and to compare cTnI values to a case-matched control group. ANIMALS: Thirty-eight client-owned dogs with permanent AV block and 38 matched control dogs. METHODS: Retrospective review of medical records. Pacemaker group consisted of dogs with AV block and dual-chamber pacing. Control group matched the study population in age and cardiac disease. cTnI was compared between pacemaker and control group on short- and long-term follow-up. Different lead types and influence of arrhythmia on cTnI were tested. RESULTS: cTnI was high at presentation (median 0.66 ng/ml; range 0.03-18.6) and showed a significant reduction over time after pacemaker implantation (p < 0.0001). Median cTnI values were significantly different between pacemaker and control group on short-term (p = 0.0004; 0.11 ng/ml, range 0.03-1.36 versus 0.06 ng/ml, range 0.03-0.46), but not on long-term follow-up (p = 0.0547; 0.14 ng/ml, range 0.03-0.73 versus 0.07 ng/ml, range 0.03-0.46). Lead type and severity of arrhythmia did not show a significant correlation to cTnI concentration. CONCLUSIONS: On long-term follow-up, cTnI remained mildly elevated in some of the pacemaker dogs but was not significantly different to the matched control group.

[A rare cause of 2:1 atrioventricular block and congestive heart failure in preterm infants: Hypocalcemia]. / Prematüre yenidoganda 2:1 atriyoventriküler blok ve konjestif kalp yetersizliginin nadir bir nedeni: Hipokalsemi.

Atrioventricular (AV) block in the neonatal period is a rare disorder. It is frequently associated with underlying structural congenital heart disease and maternal lupus. Presently described is premature baby who developed 2:1 AV block and congestive heart failure due to hypocalcemia. Dramatic clinical improvement was observed following treatment of intravenous 10% calcium gluconate. Therefore, it is suggested that serum calcium level of newborns with AV block and congestive heart failure be measured.

Diagnostic Accuracy of High-Sensitivity Cardiac Troponin T at Presentation Combined With History and ECG for Ruling Out Major Adverse Cardiac Events.

STUDY OBJECTIVE: We evaluate the diagnostic accuracy of a high-sensitivity cardiac troponin T (hs-cTnT) level less than 5 ng/L or less than or equal to 14 ng/L at emergency department (ED) presentation, combined with the emergency physician's assessment of history and ECG, for ruling out major adverse cardiac events within 30 days. METHODS: This prospective observational study enrolled consecutive ED chest pain patients. Emergency physicians' assessments of patient history and ECG were collected. The primary outcome was 30-day major adverse cardiac events, defined as acute myocardial infarction, unstable angina, cardiogenic shock, ventricular arrhythmia, atrioventricular block, cardiac arrest, or death of cardiac or unknown cause. RESULTS: A total of 1,138 patients were included in the final analysis. The combination of hs-cTnT less than 5 ng/L, a nonischemic ECG result, and a nonhigh risk history was present for 29.2% of all patients and had a sensitivity of 99.2% (95% confidence interval [CI] 95.6% to 100%), negative predictive value (NPV) of 99.7% (95% CI 98.3% to 100%), and a negative likelihood ratio of 0.02 (95% CI 0 to 0.17) for 30-day major adverse cardiac events. The same combination with hs-cTnT less than or equal to 14 ng/L was present in 66.7% of the patients and had a sensitivity of 92% (95% CI 85.8% to 96.1%), NPV of 98.7% (95% CI 97.6% to 99.4%), and negative likelihood ratio of 0.11 (95% CI 0.06 to 0.20). CONCLUSION: A single hs-cTnT result of less than 5 ng/L at ED presentation when combined with a nonischemic ECG result and a nonhigh risk history identified 29% of chest pain patients at a very low risk of 30-day major adverse cardiac events. A similar strategy with hs-cTnT less than or equal to 14 ng/L was associated with a higher miss rate.

Association of Admission Glycaemia With High Grade Atrioventricular Block in ST-Segment Elevation Myocardial Infarction Undergoing Reperfusion Therapy: An Observational Study.

Several studies have demonstrated the association between elevated admission glycaemia (AG) and the occurrence of some arrhythmias such as atrial fibrillation, ventricular tachycardia, and ventricular fibrillation after myocardial infarction. However, the impact of elevated AG on the high grade atrioventricular block (AVB) occurrence after ST-segment elevation myocardial infarction (STEMI) remains unclear. Included were 3359 consecutive patients with STEMI who received reperfusion therapy. The primary endpoint was the development of high grade AVB during hospital course. Patients were divided into non-diabetes mellitus (DM), newly diagnosed DM, and previously known DM according to the hemoglobin A1c level. The optimal AG value was determined by receiver operating characteristic curves analysis with AG predicting the high grade AVB occurrence. The best cut-off value of AG for predicting the high grade AVB occurrence was 10.05 mmol/L by ROC curve analysis. The prevalence of AG ≥ 10.05 mmol/L in non-DM, newly diagnosed DM, and previously known DM was 15.7%, 34.1%, and 68.5%, respectively. The incidence of high grade AVB was significantly higher in patients with AG ≥ 10.05  mmol/L than <10.05  mmol/L in non-DM (5.7% vs. 2.1%, P < 0.001) and in newly diagnosed DM (10.2% vs.1.4%, P < 0.001), but was comparable in previously known DM (3.6% vs. 0.0%, P = 0.062). After multivariate adjustment, AG ≥ 10.05  mmol/L was independently associated with increased risk of high grade AVB occurrence in non-DM (HR = 1.826, 95% CI 1.073-3.107, P = 0.027) and in newly diagnosed DM (HR = 5.252, 95% CI 1.890-14.597, P = 0.001). Moreover, both AG ≥ 10.05  mmol/L and high grade AVB were independent risk factors of 30-day all cause-mortality (HR = 1.362, 95% CI 1.006-1.844, P = 0.046 and HR = 2.122, 95% CI 1.154-3.903, P = 0.015, respectively). Our study suggested that elevated AG level (≥10.05  mmol/L) might be an indicator of increased risk of high grade AVB occurrence in patients with STEMI.

ECG Case of the Month: Unexpected Atrioventricular Conduction in High-Grade Atrioventricular Block. Sinus rhythm; high-grade second degree atrioventricular block with a junctional escape rhythm and three capture complexes, each with right bundle branch block aberration; possible septal myocardial infarct of indeterminate age; ST-T and U wave changes suggesting hypokalemia.

A 90-year-old man with a history of high blood pressure, a cerebrovascular accident without focal residua, dementia, and stage 3 chronic kidney disease went to the emergency department because of dizziness and near syncope. His medications were aspirin 81 mg qd, clopidogrel 75 mg qod, escitalopram oxalate 10 mg qd, Seroquel 25 mg qd, and memantine hydrochloride 10 mg qd. He had orthostatic hypotension with supine blood pressure of 173/77 mm Hg falling to 116/68 on standing, while pulse increased from 66 to 84 beats/ min. He received IV fluid and returned home. Two days later he saw his primary care physician because of episodes of dizziness and confusion. The figure shows an electrocardiogram recorded during that visit.

ECG of the Month. Unexpected Atrioventricular Conduction in High-Grade Atrioventricular Block. DIAGNOSIS: Sinus rhythm; high-grade second-degree atrioventricular block with a junctional escape rhythm and three capture complexes, each with right bundle branch block aberration; possible septal myocardial infarct of indeterminate age; ST-T and U wave changes suggesting hypokalemia.

A 90-year-old man with a history of high blood pressure, a cerebrovascular accident without focal residua, dementia, and stage 3 chronic kidney disease went to the emergency department because of dizziness and near syncope. His medications were aspirin 81 mg qd, clopidogrel 75 mg qod, escitalopram oxalate 10 mg qd, quetiapine fumarate 25 mg qd, and memantine hydrochloride 10 mg qd. He had orthrostatic hypotension with supine blood pressure of 173/77 mmHg falling to 116/68 on standing, while pulse increased from 66 to 84 beats/min. He received IV fluid and returned home. Two days later, he saw his primary care physician because of episodes of dizziness and confusion. The Figure shows an electrocardiogram recorded during that visit.

Exercise capacity and N-terminal pro-brain natriuretic peptide levels with biventricular vs. right ventricular pacing for atrioventricular block: results from the PREVENT-HF German Substudy.

AIMS: Previous studies showed unfavourable effects of right ventricular (RV) pacing. Ventricular pacing (VP), however, is required in many patients with atrioventricular (AV) block. The PREVENT-HF study explored left ventricular (LV) remodelling during RV vs. biventricular (BIV) pacing in AV block without advanced heart failure. The pre-specified PREVENT-HF German Substudy examined exercise capacity and N-terminal pro-brain natriuretic peptide (NT-proBNP). METHODS AND RESULTS: Patients with expected VP ≥80% were randomized to RV or BIV pacing. Endpoints were peak oxygen uptake (pVO2), oxygen uptake at the anaerobic threshold (VO2AT), ventilatory efficiency (VE/VCO2), and logNT-proBNP. Considering crossover, intention to treat (ITT), and on-treatment (OT) analyses of covariance (ANCOVA) were performed. For exercise testing 44 (RV: 25, BIV: 19), and for NT-proBNP 53 patients (RV: 29, BIV: 24) were included. The ITT analysis revealed significant differences in pVO2 [ANCOVA effect 2.83 mL/kg/min, confidence interval (CI) 0.83-4.91, P = 0.007], VO2AT (ANCOVA effect 2.14 mL/min/k, CI 0.14-4.15, P = 0.03), and VE/VCO2 (ANCOVA effect -5.46, CI -10.79 to -0.13, P = 0.04) favouring BIV randomization. The significant advantage in pVO2 persisted in OT analysis, while VO2AT and VE/VCO2 showed trends favouring BIV pacing. LogNT-proBNP did not differ between groups. (ITT: ANCOVA effect 0.008, CI -0.40 to +0.41, P = 0.97; OT: ANCOVA effect -0.03, CI -0.44 to 0.30, P = 0.90). CONCLUSION: Our study suggests that BIV pacing produces better exercise capacity over 1 year compared with RV pacing in patients without advanced heart failure and AV block. In contrast, we observed no significant changes of NT-proBNP. Larger trials will allow appraising the clinical usefulness of BIV pacing in AV block. ClinicalTrials.gov Identifier: NCT00170326.

[Complete atrioventricular block during lithium therapy within therapeutic range]. / Kompletter AV-Block unter Lithiumtherapie im therapeutischen Bereich.

HISTORY AND CLINICAL FINDINGS: A 69-year-old man came to the emergency unit because of vertigo and presyncope. A bipolar disorder - known since an age of 15 years - has been treated with 2 × 450 mg lithium and 100 mg perazine per day for several years (no other medications). With the exception of a low heart rate (36/min) clinical examination findings were unremarkable. INVESTIGATIONS: Electrocardiography revealed a permanent complete atrioventricular block with a heart rate of 36/min. Echocardiography showed a normal left ejection fraction (EF 65 %). Laboratory tests were mainly unremarkable, particularly the lithium levels (0,7 mmol/l) were within the therapeutic range. TREATMENT AND COURSE: Continuous treatment with orciprenaline stabilized the heart rate at an average of 52/min. After pacing with a provisional pacemaker a permanent pacemaker was implanted without complications, and the symptoms of vertigo and dizziness disappeared. Pacemaker checkup on the following day still showed a complete atrioventricular block with a heart rate of 28/min. CONCLUSION: Complete atrioventricular block secondary to chronic lithium therapy even in therapeutic levels is a rare complication with poor prognosis. Therefore it should be treated consequently.

Comparison of right ventricular apex and right ventricular outflow tract septum pacing in the elderly with normal left ventricular ejection fraction: long-term follow-up.

BACKGROUND: Whether right ventricular outfow tract septum (RVOTS) pacing is superior to right ventricular apex (RVA) pacing with respect to left ventricular synchrony, cardiac function, and remodelling in the elderly with normal left ventricular ejection fraction (LVEF), is still unknown. AIM: To assess the impact of RVOTS vs. RVA pacing on the cardiac performance of the elderly with normal LVEF during a long-term observation. METHODS: From 2007 to 2010, 65 patients with standard pacing indications for permanent pacing were recruited and randomised to receive RVA (32 patients) or RVOTS pacing (33 patients). Over a median 28 months' follow-up, available data was summarised, including New York Heart Association (NYHA) functional class, echocardiographic and pacing parameters, axis, QRS duration and plasma B-type natriuretic peptide (BNP) level. Then these values were compared between the RVA group and the RVOTS group, as well as between pacemaker pre- and post-implantation in the RVA group and in the RVOTS group, respectively. RESULTS: There were no significant differences in baseline characteristics between the RVA group and the RVOTS group. The median pacing durations did not differ significantly between the groups (31.5 months in the RVA group vs. 28 months in the RVOTS group, p = 0.728). Compared to the baseline values, LVEF decreased with RVA pacing (from 59.5 ± 6.21 to 54.22 ± 8.73, p = 0.001), but LVEF did not markedly vary in the RVOTS group (57.82 ± 6.06 and 56.94 ± 5.54, p = 0.152). The number of patients with moderate tricuspid valve regurgitation remarkably increased in the RVA group, from six (18.75%) patients to 10 (31.3%) patients, preoperatively to postoperatively (p = 0.046), but this change was not statistically significant in the RVOTS group. Compared to the RVOTS group, NYHA functional class had a deteriorated tendency in the RVA group (p = 0.071). After the implantation, the increase of median BNP level was observed in the RVA group (35 pg/mL at preimplantation and 50 pg/mL at the end of follow-up, p = 0.007); No significant change was obtained in the RVOTS group (36.4 pg/mL at pre-implantation vs. 38 pg/ml at the end of follow-up, p = 0.102). Compared to the RVA pacing group, the mean QRS width narrowed substantially in the RVOTS pacing group (from 143.56 ± 12.90 to 105.52 ± 15.21, p = 0.000). In terms of the end diastolic and systolic diameters of the left ventricular, there were no statistical variations observed during the follow-up. CONCLUSIONS: Permanent RVA pacing in elderly patients with normal LVEF led to left ventricular systolic function deterioration denoted by lower LVEF and higher BNP level. When compared to RVA pacing, RVOTS pacing had no remarkable benefit in terms of preventing cardiac remodelling.

N-terminal pro-brain natriuretic peptide and electrocardiographic variables associated with increased risk of complete atrioventricular block and mortality in patients with acute inferior myocardial infarction.

BACKGROUND: Although brain natriuretic peptide (BNP) levels are shown to be an important prognostic factor in patients with acute myocardial infarction (MI), the relationship between arrhythmias and BNP levels is not known. This study assessed whether baseline clinical factors, N-terminal-proBNP (NT-proBNP) levels and electrocardiographic patterns of acute inferior MI are associated with greater risk of developing complete atrioventricular block (CAVB) and mortality. METHODS AND RESULTS: Seventy-nine consecutive patients (52 male, 27 female with an avarage age of 64.2 ± 10.9 years) with CAVB and 119 control patients (93 male, 16 female with an average age of 57.7 ± 11.4 years) without CAVB were enrolled. Regression analysis revealed that NT-proBNP levels 〉 104 pg/mL increased the development of CAVB by 16.7 folds, 〉 1 mm ST elevation in RV4 by 2.7 folds, ratio of elevation in lead III:II 〉 1.5 by 10.1 folds but the thrombolytic therapy decreased the development of CAVB by 2.8 folds. NT-proBNP 〉 92 pg/mL increased the mortality by 8.9 folds, a ratio of ST-segment elevation in lead III:II 〉 1 by 3.1 folds, ST segment elevation 〉 1 mm in RV4 by 3.5 folds, ejection fraction 〈 35% by 24.2 folds, age 〉 65 years by 8.3 folds and CAVB by 6.8 folds, on contrary thrombolytic treatment decreased the mortality by 3.3 folds. CONCLUSIONS: Simple electrocardiographic measurements and NT-proBNP levels at admission can be used as a screening test for development of complications such as CAVB, right ventricular involvement and mortality during acute inferior wall MI.

A population-based investigation of the autoantibody profile in mothers of children with atrioventricular block.

The objective of the study was to investigate the antigen specificity and occurrence of individual autoantibodies in mothers of children diagnosed with atrioventricular (AV) block in a nation-wide setting. Patients with AV block detected before 15 years of age were identified using national quality registries as well as a network of pediatric and adult cardiologists and rheumatologists at the six university hospitals in Sweden. Patients with gross heart malformations, surgically or infectiously induced blocks were excluded. Blood samples were obtained from the mothers and maternal autoantibody profile, including the occurrence of antibodies against Ro52, Ro60, La, SmB, SmD, RNP-70k, RNP-A, RNP-C, CENP-C, Scl-70, Jo-1, ribosomal RNP and histones was investigated in 193 mothers of children with AV block by immunoblotting and ELISA. Autoantibody reactivity was detected in 48% (93/193) of the mothers of children with AV block. In autoantibody-positive mothers, the vast majority, 95% (88/93), had antibodies against Ro52, while 63% (59/93) had autoantibodies to Ro60 and 58% (54/93) had autoantibodies to La. In addition, 13% (12/93) of the autoantibody-positive mothers had antibodies to other investigated antigens besides Ro52, Ro60 and La, and of these anti-histone antibodies were most commonly represented, detected in 8% (7/93) of the mothers. In conclusion, this Swedish population-based study confirms that maternal autoantibodies may associate with heart block in the child. Further, our data demonstrate a dominant role of Ro52 antibodies in association with AV block.

Clinical and laboratory aspects of Ro/SSA-52 autoantibodies.

Anti-Ro/SSA antibodies, which were described for the first time in systemic lupus erythematosus (SLE) and Sjögren's syndrome (SS), are the most prevalent extractable nuclear antigen (ENA) specificity identified in laboratories. Two types of anti-Ro/SSA antibodies have been described, anti-SSA-52 kDa (aSSA52) and anti-SSA-60 kDa (aSSA60), each specific to different antigens. Anti-Ro/SSA52 autoantibodies are more frequent than other autoantibodies possibly because of the antigen's accessible and ubiquitous nature. The sites involved and the symptoms associated with these autoantibodies depend on the antigen's structural variability. Isolated congenital complete atrioventricular block (CAVB) shows a close association with maternal anti-Ro/SSA and anti-La/SSB antibodies; the highest relative risks of CAVB are seen in offspring of mothers with antibodies against 52-kDa Ro and 48-kDa La proteins. Anti-Ro/SSA52 antibodies have little impact on adult rheumatic autoimmune diseases or adult cardiac arrhythmias, but the course of autoimmune liver diseases is greatly worsened by their presence, and solid tumours tend to relapse. Their diagnostic role in rheumatic diseases is controversial, although a significant association between isolated anti-Ro/SSA52-kDa positivity and myositis and to a lesser extent with systemic sclerosis (SSc) has been described. However, the majority of the specific diagnosis is mostly based on the simultaneous presence of other autoantibodies that seems diagnostically more relevant.

Bitter pill to swallow: a case of accidental poisoning with digitalis purpurea.

While digitoxicity secondary to therapeutic use is frequent, due to its distinctive appearance and unpleasant taste accidental ingestion of digitalis purpurea (foxglove) is uncommon. This report relates the case of two previously healthy individuals who inadvertently consumed significant quantities of digitalis in its plant form. Both men presented in first-degree atrioventricular block and had digoxin levels of 4.9 µg/litre, but were otherwise stable and made unremarkable recoveries with repeated dose activated charcoal.

Plasma levels of B-type natriuretic peptide in children and adolescents with high degree atrioventricular block.

B-type natriuretic peptide (BNP) was measured in 43 children and adolescents with high-grade second degree or complete atrioventricular conduction block. BNP plasma level was significantly higher (p<0.01) in patients without pacemaker (n=21) than in patients with permanent pacemaker (n=26). In all four patients with measurement of BNP both before and after placement of a permanent pacemaker, individual plasma BNP decreased. Additionally, patients with dual-chamber pacing had significantly lower BNP values compared to those with single chamber ventricular pacing (p<0.05). Conclusively, high degree atrioventricular block can induce elevated plasma BNP levels and the loss of atrioventricular synchrony induce a further increase of plasma BNP.