RESUMO
RATIONALE: The treatment of dilated cardiomyopathy (DCM) has recently been greatly improved, especially with the widespread use of sacubitril/valsartan (ARNI) combination therapy. We know that ARNI-like drugs can significantly improve the symptoms of heart failure with reducing ejection fraction. However, clinical studies evaluating the safety and efficacy of ARNI in DCM-associated arrhythmia are limited, and whether individuals with arrhythmia would benefit from ARNI remains controversial. In this case, we report a patient with complete left bundle branch block (CLBBB) associated with DCM whose CLBBB returned to normal after treatment with ARNI. PATIENT CONCERNS: A 38-year-old man was admitted to the hospital for 20 days for idiopathic paroxysmal dyspnea. He presented with exacerbated dyspnea symptoms at night, accompanied by cough and sputum. DIAGNOSIS: Physical examination revealed a grade 4/6 systolic murmur could be heard in the apical area of the heart and mild edema was present in both lower limbs. Laboratory examination found that the B-type natriuretic peptide was significantly increased. Echocardiography indicated left atrial internal diameter, right ventricular internal diameter, and left ventricular diastolic diameter were enlarged and ejection fraction was significantly decreased. Besides, the pulsation of the wall was diffusely attenuated. Electrocardiogram was suggestive of tachycardia and CLBBB. A diagnosis of DCM with CLBBB was considered based on a comprehensive evaluation of the physical examination, laboratory examination, echocardiography and electrocardiogram. INTERVENTIONS: The patient was treated with ARNI at a dose of 50 mg (twice a day) at first, gradually increasing to the target dose (200 mg, twice a day) in the following 9 months as shown in Table 1, along with metoprolol 25 mg (once a day [qd]), diuretics 20 mg (qd), and aldosterone 20 mg (qd). OUTCOMES: After treatment with ARNI during the 9-month follow-up, the patient's symptoms improved, and CLBBB returned to normal. LESSONS: Clinical studies evaluating the safety and efficacy of ARNI in DCM-associated arrhythmia are limited, and whether individuals with arrhythmia would benefit from ARNI remains controversial. This report will help to instruct the clinical treatment of DCM patients with CLBBB and the potential application of ARNI.
Assuntos
Cardiomiopatia Dilatada , Insuficiência Cardíaca , Adulto , Aminobutiratos , Antagonistas de Receptores de Angiotensina/uso terapêutico , Compostos de Bifenilo/uso terapêutico , Bloqueio de Ramo/induzido quimicamente , Bloqueio de Ramo/complicações , Bloqueio de Ramo/tratamento farmacológico , Cardiomiopatia Dilatada/complicações , Cardiomiopatia Dilatada/tratamento farmacológico , Combinação de Medicamentos , Insuficiência Cardíaca/tratamento farmacológico , Humanos , Masculino , Volume Sistólico , Tetrazóis/uso terapêutico , Resultado do Tratamento , Valsartana/uso terapêuticoRESUMO
INTRODUCTION: Alcohol septum ablation (ASA) is a treatment option for hypertrophic obstructive cardiomyopathy (HOCM). We examined the impact of ASA-induced bundle branch block (BBB) on clinical and hemodynamic features. METHODS AND RESULTS: We retrospectively analysed 98 HOCM patients with regard to ASA-induced BBB. Clinical examination was performed at baseline, early after ASA and at chronic follow-up (FU). ASA reduced left ventricular outflow tract gradient (LVOTG) during chronic FU (69.2 ± 41.6 pre vs. 31.8 ± 30.3 mmHg post ASA; p < 0.05) and interventricular septal diameter (21.7 ± 3.4 pre vs. 18.7 ± 5.0 mm post ASA; p < 0.05). ASA-induced early right BBB (RBBB) until discharge was observed in 44.9% and chronic RBBB at FU in 32.7%. Left BBB (LBBB) occurred in 13.3% early after ASA and in only 4.1% at chronic FU. Chronic RBBB was associated with more pronounced exercise-induced LVOTG reduction (102.1 ± 55.2 with vs. 73.6 ± 60.0 mmHg without; p < 0.05). 6-min-walk-test (6-MWT) and NYHA class were not affected by RBBB. LBBB had no influence on LVOTG, 6-MWT and symptoms. More ethanol was injected in patients with early RBBB (1.1 ± 0.4 vs. 0.8 ± 0.3 ml without; p < 0.05), who also showed higher mean CK release (827 ± 341 vs. 583 ± 279 U/l without; p < 0.05). Pacemaker implantation during FU was necessary in 11.5% of patients with early RBBB, 3.1% with chronic RBBB, 7.7% with early LBBB and 0% with chronic LBBB (p = n.s. for BBB vs. no BBB). CONCLUSION: ASA-induced RBBB is associated with a higher volume of infused ethanol and higher maximum CK release. RBBB does not adversely affect the clinical outcome or need for pacemaker implantation but was associated with higher exercise-induced LVOTG reduction during chronic FU.
Assuntos
Técnicas de Ablação/efeitos adversos , Bloqueio de Ramo/induzido quimicamente , Cardiomiopatia Hipertrófica/cirurgia , Etanol/efeitos adversos , Septos Cardíacos/cirurgia , Feminino , Hemodinâmica/efeitos dos fármacos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Amiodarone is commonly used for the treatment of supraventricular and ventricular arrhythmias. As a class III antiarrhythmic drug, it prolongs phase III of the cardiac action potential leading to QT interval prolongation. Therefore, the QTc interval should be monitored during amiodarone up-titration to prevent proarrhythmia. However, QTc monitoring in bundle branch block requires some modification as outlined in this case report. The normal upper value of QT interval has been set at 450â¯ms for males and 460â¯ms for females. Patients with preexisting bundle branch block (BBB) by definition exhibit wider QRS intervals, ranging between 120 and 200â¯ms. This 'augmented' QT interval duration is mainly driven by the prolonged time of ventricular depolarization, rather than the time of ventricular repolarization. This inherent QT interval prolongation in BBB can be corrected with specifically designed electrocardiographic formulas. Nevertheless, accurate QT interval calculation at very low or high heart rates remains challenging.
Assuntos
Amiodarona , Síndrome do QT Longo , Amiodarona/efeitos adversos , Bloqueio de Ramo/induzido quimicamente , Bloqueio de Ramo/diagnóstico , Bloqueio de Ramo/tratamento farmacológico , Eletrocardiografia , Feminino , Frequência Cardíaca , Humanos , Síndrome do QT Longo/induzido quimicamente , Síndrome do QT Longo/diagnóstico , Síndrome do QT Longo/tratamento farmacológico , MasculinoRESUMO
A 33-year-old man had verapamil-sensitive ventricular tachycardia (VT) with a right bundle branch block (RBBB) and right axis deviation. Programmed stimulation from the para-Hisian region induced ventricular tachycardias (VT1 or VT2). VT1 was entrained during pacing from the para-Hisian region. A single para-Hisian stimulation antidromically captured the proximal portion of the left anterior fascicle (LAF), but the cycle length of VT2 remained unchanged. This observation indicated that the upper limb of the LAF was a bystander of the reentry circuit. We have clarified this mechanism with applying a single premature stimulation from the para-Hisian region.
Assuntos
Ablação por Cateter , Taquicardia Ventricular , Adulto , Fascículo Atrioventricular , Bloqueio de Ramo/induzido quimicamente , Bloqueio de Ramo/complicações , Bloqueio de Ramo/diagnóstico , Eletrocardiografia , Humanos , Masculino , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/cirurgia , VerapamilAssuntos
Antidepressivos/efeitos adversos , Arritmias Cardíacas/induzido quimicamente , Tratamento Farmacológico da COVID-19 , Transtorno Depressivo/tratamento farmacológico , Cardiopatias/fisiopatologia , Antivirais/efeitos adversos , Arritmias Cardíacas/etiologia , Fibrilação Atrial/fisiopatologia , Bloqueio Atrioventricular/induzido quimicamente , Bloqueio de Ramo/induzido quimicamente , COVID-19/fisiopatologia , Cloroquina/efeitos adversos , Transtorno Depressivo/fisiopatologia , Humanos , Hidroxicloroquina/efeitos adversos , Síndrome do QT Longo/induzido quimicamente , Torsades de Pointes/induzido quimicamenteRESUMO
A 70-year-old woman with HER2+/ER+ breast cancer on adjuvant trastuzumab therapy without a history of cardiovascular disease presented with respiratory failure from influenza and was found to have intermittent left bundle branch block (LBBB) with new onset systolic heart failure. Her course was complicated by polymorphic ventricular tachycardia and recurrent chest pain. Significant investigations included a normal cardiac MRI and cardiac catheterisation with unobstructed coronaries. It was determined that the aetiology of her heart failure was trastuzumab-induced cardiotoxicity after comprehensive workup. This case highlights an uncommon presentation of LBBB and the steps taken to diagnose a rare cardiomyopathy.
Assuntos
Antineoplásicos Imunológicos/efeitos adversos , Bloqueio de Ramo/induzido quimicamente , Insuficiência Cardíaca Sistólica/induzido quimicamente , Trastuzumab/efeitos adversos , Idoso , Neoplasias da Mama/química , Neoplasias da Mama/tratamento farmacológico , Bloqueio de Ramo/fisiopatologia , Cardiotoxicidade/complicações , Eletrocardiografia , Feminino , HumanosRESUMO
Novel coronavirus disease (COVID-19) is a highly contagious disease caused by severe acute respiratory distress syndrome coronavirus-2 that has resulted in the current global pandemic. Currently, there is no available treatment proven to be effective against COVID-19, but multiple medications, including hydroxychloroquine (HCQ), are used off label. We report the case of a 60-year-old woman without any cardiac history who developed right bundle brunch block and critically prolonged corrected electrocardiographic QT interval (QTc 631 ms) after treatment for 3 days with HCQ, which resolved on discontinuation of the medication. This case highlights a significant and potentially life-threatening complication of HCQ use.
Assuntos
Bloqueio de Ramo/induzido quimicamente , Infecções por Coronavirus/tratamento farmacológico , Hidroxicloroquina/efeitos adversos , Hidroxicloroquina/uso terapêutico , Síndrome do QT Longo/induzido quimicamente , Pneumonia Viral/tratamento farmacológico , Betacoronavirus , Brunei , COVID-19 , Ecocardiografia , Feminino , Humanos , Pessoa de Meia-Idade , Pandemias , SARS-CoV-2RESUMO
PURPOSE: Tricyclic antidepressants have been shown to affect electrocardiogram (ECG) parameters, but there is limited evidence in relation to the serum concentrations. Therefore, we aimed to evaluate a prediction of cardiac risk in amitriptyline- and doxepin-treated patients by serum concentrations. PATIENTS AND METHODS: The association between serum concentrations of amitriptyline (n = 100) and doxepin (n = 71) and ECG parameters was retrospectively examined using linear regression analysis. Mann-Whitney U tests were applied to evaluate differences in QTc intervals in patients with serum concentrations above and below the upper limit of the therapeutic reference range, as well as the alert level of each target drug. RESULTS: The sum serum concentration of amitriptyline and the nortriptyline serum concentration were significantly associated with an increased PQ interval (p = 0.020, p = 0.007), as well as with increased QTcB (p = 0.012, p < 0.001) and QTcF intervals (p = 0.025, p < 0.001). The nortriptyline concentration was significantly associated with the QRS interval (p = 0.003). In patients with active moiety concentrations above the alert level (300 ng/ml) and nortriptyline concentrations above the reference range (170 ng/ml), the QTcB interval was significantly prolonged (p = 0.032, p = 0.007). No significant association with any ECG parameter was detected for doxepin serum concentrations. CONCLUSION: The effect of amitriptyline on ECG parameters may be explained by nortriptyline alone. Accordingly, with increasing nortriptyline concentrations, the potential risk for an atrioventricular block, a bundle branch block, and prolongation of QTc interval may increase significantly.
Assuntos
Amitriptilina/efeitos adversos , Antidepressivos Tricíclicos/efeitos adversos , Testes de Função Cardíaca/efeitos dos fármacos , Nortriptilina/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Amitriptilina/sangue , Amitriptilina/uso terapêutico , Antidepressivos Tricíclicos/uso terapêutico , Bloqueio Atrioventricular/induzido quimicamente , Bloqueio de Ramo/induzido quimicamente , Doxepina/efeitos adversos , Doxepina/análogos & derivados , Doxepina/sangue , Doxepina/uso terapêutico , Eletrocardiografia , Feminino , Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND Trazodone is widely used in the treatment of depression, anxiety, and insomnia. It is thought to have a safe cardiac profile due to the relative lack of anticholinergic effects. Publications about cardiac toxicities of trazodone are scant. CASE REPORT A 55-year-old woman presented with acute disorder of consciousness secondary to an intentional trazodone overdose. She was found to have seizure activity without cerebral edema. The initial electrocardiogram was unremarkable, with a normal QTc interval. She eventually developed QTc prolongation that evolved into ventricular tachycardia, and then into a transient right bundle-branch block, left anterior fascicular block, and variable degrees of atrioventricular nodal blocks at 12-24 h after ingestion. She then developed generalized tonic-clonic seizures, cardiogenic shock, and respiratory arrest. She was intubated and treated with antiepileptics, norepinephrine, and dopamine infusion. QTc interval prolongation gradually resolved and the various forms of heart block did not recur after at 24-36 h. She did not require transcutaneous pacing, and was successfully extubated with intact neurological function. CONCLUSIONS Fatal arrhythmias can occur in trazodone overdose. Close monitoring and supportive care are crucial for patient survival.
Assuntos
Ansiolíticos/efeitos adversos , Bloqueio de Ramo/induzido quimicamente , Overdose de Drogas/complicações , Síndrome do QT Longo/induzido quimicamente , Convulsões/induzido quimicamente , Taquicardia Ventricular/induzido quimicamente , Trazodona/efeitos adversos , Anticonvulsivantes/uso terapêutico , Bloqueio de Ramo/diagnóstico por imagem , Bloqueio de Ramo/tratamento farmacológico , Dopamina/uso terapêutico , Eletrocardiografia , Feminino , Humanos , Síndrome do QT Longo/diagnóstico por imagem , Síndrome do QT Longo/tratamento farmacológico , Pessoa de Meia-Idade , Norepinefrina/uso terapêutico , Taquicardia Ventricular/diagnóstico por imagem , Taquicardia Ventricular/tratamento farmacológicoAssuntos
Antiarrítmicos/intoxicação , Antibacterianos/efeitos adversos , Fibrilação Atrial/tratamento farmacológico , Bradicardia/induzido quimicamente , Bloqueio de Ramo/induzido quimicamente , Claritromicina/efeitos adversos , Digoxina/intoxicação , Infecções por Helicobacter/tratamento farmacológico , Taquicardia Ventricular/induzido quimicamente , Injúria Renal Aguda/induzido quimicamente , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/tratamento farmacológico , Idoso de 80 Anos ou mais , Amoxicilina/uso terapêutico , Fibrilação Atrial/complicações , Bradicardia/diagnóstico , Bradicardia/tratamento farmacológico , Bloqueio de Ramo/diagnóstico , Bloqueio de Ramo/tratamento farmacológico , Interações Medicamentosas , Eletrocardiografia , Feminino , Infecções por Helicobacter/complicações , Helicobacter pylori , Humanos , Hiperpotassemia/induzido quimicamente , Hiperpotassemia/diagnóstico , Hiperpotassemia/tratamento farmacológico , Fragmentos Fab das Imunoglobulinas/uso terapêutico , Omeprazol/uso terapêutico , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/tratamento farmacológicoRESUMO
It was aimed to investigate possible late cardiac effects of Sulfur mustard (SM) exposure in Iranian veterans. Thirty-eight veterans with late complications of SM exposure were investigated. Clinical history, physical examinations, 12 leads electrocardiography and transthoracic echocardiography were performed. Computed tomography coronary angiography (CTCA) was performed as clinically indicated for angiographic assessment and patients were stratified according to the CTCA findings. Incomplete right bundle branch block and right axis deviation were detected in 3 (7.9%) and 4 (10.5%) cases, respectively. Mean value of left ventricular ejection fraction was 55.7 ± 2.9%. Different degrees of right ventricular dilation was observed in seven (18.4%) patients. All the patients showed mild to moderate degrees of tricuspid regurgitation. Increased pulmonary artery pressure (PAP) was detected in 16 (42.1%) patients. Out of 18 patients who underwent CTCA, non-obstructive and obstructive coronary artery disease (CAD) were observed in three (16.66%) and eight (44.44%) patients, respectively. CAD was stratified to single vessel (5.5%), two vessels (27.8%) and three vessels disease (11.1%). Mean coronary artery calcium score was 50.91 ± 115.58. SM has cardiovascular toxicity, as a delayed complication of this chemical warfare poisoning.
Assuntos
Substâncias para a Guerra Química/intoxicação , Cardiopatias/induzido quimicamente , Gás de Mostarda/intoxicação , Exposição Ocupacional/efeitos adversos , Saúde dos Veteranos , Adulto , Idoso , Bloqueio de Ramo/induzido quimicamente , Cardiotoxicidade , Doença da Artéria Coronariana/induzido quimicamente , Estudos Transversais , Cardiopatias/diagnóstico , Cardiopatias/fisiopatologia , Cardiopatias/terapia , Humanos , Irã (Geográfico) , Masculino , Pessoa de Meia-Idade , Prognóstico , Medição de Risco , Fatores de Tempo , Insuficiência da Valva Tricúspide/induzido quimicamente , Calcificação Vascular/induzido quimicamente , Disfunção Ventricular Esquerda/induzido quimicamente , Função Ventricular Esquerda/efeitos dos fármacos , Função Ventricular Direita/efeitos dos fármacos , Remodelação Ventricular/efeitos dos fármacosAssuntos
Cardiotoxicidade/epidemiologia , Melanoma/complicações , Inibidores de Proteínas Quinases/administração & dosagem , Vemurafenib/administração & dosagem , Bloqueio de Ramo/induzido quimicamente , Bloqueio de Ramo/fisiopatologia , Cardiotoxicidade/fisiopatologia , Ecocardiografia/métodos , Eletrocardiografia/métodos , Feminino , Humanos , Imageamento por Ressonância Magnética/métodos , Melanoma/tratamento farmacológico , Melanoma/genética , Melanoma/secundário , Pessoa de Meia-Idade , Terapia de Alvo Molecular/efeitos adversos , Terapia de Alvo Molecular/métodos , Mutação , Peptídeo Natriurético Encefálico/sangue , Metástase Neoplásica/patologia , Inibidores de Proteínas Quinases/efeitos adversos , Neoplasias Cutâneas/patologia , Troponina I/sangue , Vemurafenib/efeitos adversos , Disfunção Ventricular Esquerda/diagnóstico por imagem , Suspensão de TratamentoRESUMO
WHAT IS KNOWN AND OBJECTIVE: Toxic prolongation of the QRS interval most often results from blockade of cardiac voltage-gated sodium channels and manifests on electrocardiogram with a right bundle-branch block-like morphology. Rarely, a left bundle-branch block (LBBB) morphology has been reported. CASE REPORT: We report a case of transient LBBB resultant from ingestion of lamotrigine and citalopram which was refractory to sodium bicarbonate therapy and eventually resolved spontaneously. WHAT IS NEW AND CONCLUSION: Cases of toxic LBBB are less likely to respond to bicarbonate therapy, suggesting that this finding is due to a mechanism other than sodium channel blockade.
Assuntos
Arritmias Cardíacas/induzido quimicamente , Bicarbonatos/efeitos adversos , Bloqueio de Ramo/induzido quimicamente , Citalopram/efeitos adversos , Eletrocardiografia/efeitos dos fármacos , Lamotrigina/efeitos adversos , Adulto , Feminino , HumanosRESUMO
Wellens' syndrome represents critical occlusion of the proximal left anterior descending coronary artery. Electrocardiographic changes similar to Wellens' wave are not exceptional to acute coronary occlusion and can also be seen in cardiac and non-cardiac conditions, such as left ventricular hypertrophy, persistent juvenile T wave, bundle branch blocks, cerebral haemorrhage, pulmonary oedema, pulmonary embolism, pheochromocytoma, Takotsubo syndrome, digitalis and cocaine-induced coronary vasospasm. Cocaine-induced pseudo-Wellens' syndrome should be considered as one of the differentials, since cocaine is used frequently by young adults and can cause left anterior descending coronary vasospasm mimicking Wellens' syndrome. Initiation of the beta-blocking agent in pseudo-Wellens' syndrome as a part of acute coronary syndrome management can be disastrous. We illustrated a case of cocaine-induced pseudo-Wellens' syndrome presented with typical chest pain associated with Wellenoid ECG.
Assuntos
Bloqueio de Ramo/diagnóstico , Cocaína/efeitos adversos , Antagonistas Adrenérgicos beta/administração & dosagem , Antagonistas Adrenérgicos beta/uso terapêutico , Bloqueio de Ramo/induzido quimicamente , Bloqueio de Ramo/diagnóstico por imagem , Bloqueio de Ramo/tratamento farmacológico , Dor no Peito/etiologia , Angiografia Coronária , Diagnóstico Diferencial , Eletrocardiografia , Humanos , Masculino , Pessoa de Meia-Idade , SíndromeRESUMO
Cytomegalovirus (CMV) can rarely cause severe manifestations in immunocompetent individuals. Hereby, we report a twelve-year-old boy who presented with tachycardia, tachypnea, fever and leukocytosis, which progressed to hypoxemic respiratory failure and severe acute respiratory distress syndrome (ARDS). Subsequently, he developed multi-organ failure despite the ongoing full supportive care and empiric broad spectrum antibiotics. Cytomegalovirus infection was diagnosed by Polymerase Chain Reaction (PCR) in blood and histopathological examination of lung biopsy. Immunological work up for the child was unremarkable. Ganciclovir therapy was introduced and showed significant improvement until full recovery. However, our patient developed transient heart block as a rare complication for Ganciclovir therapy throughout his course. We present this case with literature review for the CMV infection associated morbidity and mortality among immunocompetent children.
Assuntos
Antivirais/efeitos adversos , Arritmias Cardíacas/induzido quimicamente , Infecções por Citomegalovirus/complicações , Citomegalovirus/isolamento & purificação , Ganciclovir/efeitos adversos , Insuficiência de Múltiplos Órgãos/virologia , Pneumonia Viral/virologia , Síndrome Respiratória Aguda Grave/virologia , Antivirais/administração & dosagem , Bloqueio de Ramo/induzido quimicamente , Criança , Citomegalovirus/genética , Infecções por Citomegalovirus/tratamento farmacológico , Infecções por Citomegalovirus/imunologia , Ganciclovir/administração & dosagem , Humanos , Imunocompetência/imunologia , Leucocitose , Masculino , Insuficiência de Múltiplos Órgãos/tratamento farmacológico , Insuficiência de Múltiplos Órgãos/imunologia , Pneumonia Viral/tratamento farmacológico , Pneumonia Viral/imunologia , Síndrome Respiratória Aguda Grave/tratamento farmacológico , Síndrome Respiratória Aguda Grave/imunologia , Taquicardia , TaquipneiaAssuntos
Amitriptilina/toxicidade , Antidepressivos Tricíclicos/toxicidade , Bloqueio de Ramo/induzido quimicamente , Transtorno Depressivo Maior/tratamento farmacológico , Overdose de Drogas/complicações , Adulto , Bloqueio de Ramo/diagnóstico , Transtorno Depressivo Maior/psicologia , Overdose de Drogas/psicologia , Eletrocardiografia , Humanos , Masculino , Ideação SuicidaRESUMO
We present a case of a 74-year-old woman, who was on nitrofurantoin treatment for urinary tract infection (UTI), with fever and chills 7 hours after taking nitrofurantoin. She was hospitalised and evaluated for worsening UTI and sepsis. Initially, it appeared to be secondary to post-UTI sepsis because of possible resistant infection or conditions like pulmonary embolism or acute hepatitis. The patient also developed systemic inflammatory response syndrome, left bundle branch block (LBBB), thrombocytopaenia and transaminitis. Considering the side effects of nitrofurantoin, it was stopped. The patient showed improvement and recovered completely with symptomatic and supportive treatment. During follow-up visits with her primary care physician, thrombocytopaenia, transaminitisandLBBB were found to have been resolved.