Significance of chronic tachycardia in systemic lupus erythematosus

Case report: Severe sinus tachycardia as a leading manifestation of systemic lupus erythematosus flare

Systemic lupus erythematosus (SLE) is known to have various cardiac manifestations, including arrhythmias and tachycardia. However, it is rare to encounter severe sinus tachycardia as a presenting feature in patients with SLE. Herein, we present a case of a 32-year-old Filipino female with a history of recurrent hospital admissions due to palpitations and uncontrolled tachycardia. Despite trying various symptomatic treatments, her symptoms remained persistent. Ultimately, the patient was diagnosed with SLE during her hospital stay. Eventually, her symptoms improved after initiating steroids. In conclusion, severe sinus tachycardia could be an unusual presentation of SLE that physicians should consider.

A deeper look into the functions of right ventricle using three-dimensional echocardiography: the forgotten ventricle in children with systemic lupus erythematosus

Studies on the right ventricular dysfunction (RV) in systemic lupus erythematosus (SLE) patients are limited, particularly in the pediatric age group. The study aimed to identify subclinical RV alterations in childhood-onset SLE (c-SLE) using conventional and three-dimensional echocardiography (3DE). Forty SLE pediatric patients and 40 healthy controls were included. Disease activity and chronicity were evaluated by SLE disease activity index (SLEDAI) score and SLE damage index (SDI). Participants underwent detailed RV echocardiographic examination with conventional and 3DE assessment using 3D auto RV software. Patients included 35/40 (87.5%) females with mean age of 15.6 ± 1.7 years. Using conventional pulmonary artery systolic pressure echocardiography-derived measurement, none of the c-SLE patients had pulmonary hypertension. By 3DE, RV end-systolic and end-diastolic volumes (p = < 0.001, 0.02, respectively) were greater, whereas 3D-derived RV ejection fraction (p < 0.001), septal, and lateral longitudinal strain (both p < 0.001) were lower in SLE. SDI displayed a significant correlation with 3D auto RV ejection fraction (EF), tricuspid annular plane systolic excursion (TAPSE), fractional area change, and RV longitudinal strain (RVLS)-free wall (p = 0.01, 0.003, 0.007, and < 0.001, respectively). Cumulative SLEDAI score also showed a significant correlation with RV EF, TAPSE, FAC, and RVLS-free wall (p = 0.03, 0.007, 0.002, and < 0.001, respectively). By multivariate regression analysis, SDI remained an independent predictor of RVLS-free wall (ß coefficient - 0.4, p = 0.03) and TAPSE (ß - 0.5, p = 0.02).  Conclusion: Subtle right ventricular myocardial dysfunction could be detected in childhood-onset SLE patients, especially via 3D-derived auto RV echocardiographic parameters, despite the absence of evident pulmonary hypertension. These parameters correlate with the SLE disease activity and chronicity scores. What is Known: •Diseases of the cardiovascular system are one of the most common causes of morbidity and mortality in SLE patients. •RV labeled the forgotten ventricle in many diseases, was also forgotten in SLE patients and has been rarely addressed in adults, with scarce research in pediatrics. What is New: •Right ventricular functions are affected in children with SLE in comparison to healthy controls, especially three-dimensional echocardiography-derived parameters, which is an aspect that has not been investigated in previous research in the pediatric age group. •Some of the detected myocardial dysfunctions of the right ventricle correlated with SLE disease activity and chronicity-related scores.

Influence of disease severity and cardiac autonomic tone on ventricular repolarization and dispersion in electrocardiographic assessment of patients with systemic lupus erythematosus

Background

There are no data on the influence of disease severity and cardiac autonomic tone on ventricular repolarization and dispersion in 24-hour Holter monitoring in systemic lupus erythematosus (SLE).

Methods

Consecutive 92 SLE and 51 healthy subjects were studied. The standard 12-lead electrocardiography (ECG), Holter monitoring with heart rate turbulence (HRT) and QT, Tp-e and Tp-e/QT ratio assessment (including corrected values) were performed. Subjects with conditions causing repolarization abnormalities or insufficient number of beats suitable for QT evaluation were excluded (17 SLE and 8 controls).

Results

Finally, 75 SLE and 43 sex- and age-matched controls were included to the study. In SLE patients, the median disease severity score (Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC/ACR-DI)) was 3.0. The mean values of QTc, cTp-e and cTp-e/QTc were significantly higher in SLE patients than in controls. QTc ≥ 460 ms was observed in 18.7% of patients using standard ECG and in 58.7% using Holter monitoring. With Holter monitoring, patients with SLICC/ACR-DI >3.0 presented longer QTc than those with SLICC/ACR-DI ≤3.0 (418±15 vs. 409 ± 16, p = 0.04), while cTp-e and cTp-e/QTc values were similar. Patients with abnormal HRT presented longer cTp-e and higher cTp-e/QTc than those with normal HRT (92 ± 52 vs. 71 ± 16 ms, p = 0.04; 0.244 ± 0.126 vs. 0.187 ± 0.035, p = 0.03), while QTc values were similar. No differences in QT and Tp-e parameters were observed according to disease duration.

Conclusion

In SLE patients, Holter monitoring revealed QTc prolongation more frequently than standard ECG. Longer QTc values were observed in patients with more advanced disease, while increased cTp-e and cTp-e/QTc were related to cardiac autonomic dysfunction expressed by abnormal HRT.

Radiofrequency catheter ablation for inappropriate sinus tachycardia in a patient with systemic lupus erythematosus: a case report

Background

Systemic lupus erythematosus (SLE) is known to cause inappropriate sinus tachycardia (IST). However, there is limited evidence available with regard to the treatment of IST in this setting. In this article, we report a case of drug refractory IST in a patient with SLE treated with radiofrequency catheter ablation (RFCA) using a non-contact mapping system.

Case summary

A 33-year-old woman had been diagnosed with SLE in 2001. She presented with complaints of persistent palpitations for 1 month and persistent sinus tachycardia. She underwent RFCA using a non-contact mapping system for drug refractory IST. The voltage and activation maps did not show obvious differences in the earliest activation site at heart rates (HRs) 90–150 b.p.m. In contrast, the areas of breakout sites were clearly distinguished between those from the normal P-wave zones at HR <140 b.p.m. and those from higher rate sites at HR >140 b.p.m. Radiofrequency catheter ablation was performed in those areas as the target for ablation. Thereafter, the symptoms steadily disappeared and the maximum HR—using 24-h Holter monitoring—decreased from 156 to 120 b.p.m.

Discussion

Radiofrequency catheter ablation using a non-contact mapping system was applied to the treatment of drug refractory IST in a patient with SLE. Of note, IST in such patients may be left untreated. This approach may be considered as a first-line therapy option for drug refractory IST in patients with SLE.

Heart rate variability in patients with systemic lupus erythematosus: a systematic review and methodological considerations

Aim The aim of this review was to summarize current knowledge about the scientific findings and potential clinical utility of heart rate variability measures in patients with systemic lupus erythematosus. Methods PubMed, Embase and Scopus databases were searched for the terms associated with systemic lupus erythematosus and heart rate variability, including controlled vocabulary, when appropriate. Articles published in English and available in full text were considered. Finally, 11 publications were selected, according to the systematic review protocol and were analyzed. Results In general, heart rate variability, measured in the time and frequency domains, was reported to be decreased in patients with systemic lupus erythematosus compared with controls. In some systemic lupus erythematosus studies, heart rate variability was found to correlate with inflammatory markers and albumin levels. A novel heart rate variability measure, heart rate turbulence onset, was shown to be increased, while heart rate turbulence slope was decreased in systemic lupus erythematosus patients. Reports of associations of changes in heart rate variability parameters with increasing systemic lupus erythematosus activity were inconsistent, showing decreasing heart rate variability or no relationship. However, the low/high frequency ratio was, in some studies, reported to increase with increasing disease activity or to be inversely correlated with albumin levels. Conclusions Patients with systemic lupus erythematosus have abnormal heart rate variability, which reflects cardiac autonomic dysfunction and may be related to inflammatory cytokines but not necessarily to disease activity. Thus measurement of heart rate variability could be a useful clinical tool for monitoring autonomic dysfunction in systemic lupus erythematosus, and may potentially provide prognostic information.

Prevalence of resting-ECG abnormalities in systemic lupus erythematosus: a single-center experience

Cardiovascular complications are a major cause of morbidity and even mortality among systemic lupus erythematosus (SLE) patients. Whether cardiac arrhythmias contribute to this burden among SLE patients, however, is not currently known. The goal of this study was to determine the prevalence of cardiac conduction abnormalities among SLE patients from a single center. We retrospectively reviewed the medical records of SLE patients who had 12-lead electrocardiograms (ECGs) available from various settings at a single academic center over the period of 10 years. In addition, ICD-9 codes for arrhythmias were obtained for the SLE patients whose ECGs were reviewed. The hospital setting (in-patient, out-patient, emergency department) and the indication for obtaining the ECG were evaluated. Two hundred thirty-five SLE patients had available ECGs. Sinus tachycardia was most common (18%). With direct ECG review, tachyarrhythmias were found in 6% of SLE patients, with the most common being atrial fibrillation (3%). Atrial fibrillation was seen even more frequently (9%) when ICD-9 codes were reviewed. No patients had brady-arrhythmias. QT prolongation was present in 17% of patients upon direct ECG review. More ECGs with tachyarrhythmias and QT prolongation were found among inpatients, with preoperative evaluation and gastrointestinal symptoms being the most common indications. Sinus tachycardia was the most common finding seen among our SLE patients with ECGs. Further study into the possible mechanisms behind this is warranted, including the possibility of autonomic nervous system involvement in SLE.