Are late potentials operative in arrhythmias following methylprednisolone pulse therapy

Drug-induced atrial fibrillation

Atrial fibrillation (AF) is a common cardiac arrhythmia that is associated with severe consequences, including symptoms, haemodynamic instability, increased cardiovascular mortality and stroke. While other arrhythmias such as torsades de pointes and sinus bradycardia are more typically thought of as drug induced, AF may also be precipitated by drug therapy, although ascribing causality to drug-associated AF is more difficult than with other drug-induced arrhythmias. Drug-induced AF is more likely to occur in patients with risk factors and co-morbidities that commonly co-exist with AF, such as advanced age, alcohol consumption, family history of AF, hypertension, thyroid dysfunction, sleep apnoea and heart disease. New-onset AF has been associated with cardiovascular drugs such as adenosine, dobutamine and milrinone. In addition, medications such as corticosteroids, ondansetron and antineoplastic agents such as paclitaxel, mitoxantrone and doxorubicin have been reported to induce AF. Whether bisphosphonate drugs are associated with new-onset AF remains controversial and requires further study. The potential contribution of specific drug therapy should be considered when patients present with new-onset AF.

Cardiac disease in chronic obstructive pulmonary disease

The cardiac manifestations of chronic obstructive pulmonary disease (COPD) are numerous. Impairments of right ventricular dysfunction and pulmonary vascular disease are well known to complicate the clinical course of COPD and correlate inversely with survival. The pathogenesis of pulmonary vascular disease in COPD is likely multifactorial and related to alterations in gas exchange and vascular biology, as well as structural changes of the pulmonary vasculature and mechanical factors. Several modalities currently exist for the assessment of pulmonary vascular disease in COPD, but right heart catheterization remains the gold standard. Although no specific therapy other than oxygen has been generally accepted for the treatment of pulmonary hypertension in this population, there has been renewed interest in specific pulmonary vasodilators. The coexistence of COPD and coronary artery disease occurs frequently. This association is likely related to shared risk factors as well as similar pathogenic mechanisms, such as systemic inflammation. Management strategies for the care of patients with COPD and coronary artery disease are similar to those without COPD, but care must be given to address their respiratory limitations. Arrhythmias occur frequently in patients with COPD, but are rarely fatal and can generally be treated medically. Use of beta-blockers in the management of cardiac disease, while a theoretical concern in patients with increased airway resistance, is generally safe with the use of cardioselective agents.

Sinus bradycardia after intravenous pulse methylprednisolone

High-dose intravenous pulse methylprednisolone is an important therapeutic modality for many autoimmune conditions in both children and adults. Adverse effects of this therapy include hypertension, hyperglycemia, and, in children, behavioral changes. Cardiac rhythm disturbances, both tachyarrhythmias and bradyarrhythmias, have been reported in adults but much less commonly in children. Here we report our experience over a 6-month period with 5 children with rheumatic diseases who developed sinus bradycardia during consecutive daily therapy with intravenous pulse methylprednisolone. Reductions in resting heart rate of between 35% and 50% of baseline were observed in each case. All patients were asymptomatic, and all recovered spontaneously over a variable period of time after cessation of pulse therapy. Sinus bradycardia after repeated administration of high-dose pulse methylprednisolone in children may be more common than previously appreciated.

First report of supraventricular tachycardia after intravenous pulse methylprednisolone therapy, with a brief review of the literature

The occurrence of supraventricular tachycardia after high-dose intravenous methylprednisolone pulse therapy (HIVMPT) in a patient with active rheumatoid arthritis is described for the first time. This case report further expands the range of arrhythmias that can occur with HIVMPT. Other arrhythmias previously reported to occur after HIVMPT include atrial fibrillation, atrial flutter, junctional rhythm, and ventricular tachycardia. To the best of our knowledge, supraventricular tachycardia has not been reported previously, although severe bradycardia, hypotension, asystole, cardiovascular collapse, and sudden death have been documented. A review of the literature indicates that these case reports not withstanding, HIVMPT is generally safe, and cardiovascular toxicity is rare. However, close supervision with repeated measurements of blood pressure, electrocardiogram, and blood electrolytes is mandatory during and immediately after HIVMPT, especially for patients with pre-existing cardiovascular disease, and the lowest effective dose of methylprednisolone should be infused at a slow rate.

Efficacy of methylprednisolone pulse therapy in steroid-resistant nephrotic syndrome

Steroid-resistant nephrotic syndrome (SRNS) in children is intractable, and the optimal treatment regimen is not known. We investigated the efficacy of methylprednisolone pulse therapy (MPT) in SRNS patients. Using only MPT plus heparin, we have treated ten pediatric SRNS patients that were resistant to cyclophosphamide (CPM) or cyclosporin A (CsA) and predicted to have a very poor prognosis. Administration of 30 mg/kg per day methylprednisolone with heparin for 3 days was taken as one course, and this was given 14 times over 2 years. One patient discontinued MPT because of peritonitis. Of the remaining nine patients, complete remission was achieved by four patients, persistent mild proteinuria remained in three patients, and no effect was observed in two patients. All patients that had been diagnosed with minimal change (MC) pathology ( n=3) at the initial renal biopsy achieved complete remission. Observed adverse events were peritonitis in one patient and a transient decrease in pulse rate only during MPT in one patient. These results demonstrate that MPT with heparin can induce remission in children with SRNS, even when the patient is resistant to CPM and CsA.

Atrial Fibrillation Induced by Oral Methylprednisolone

Objective

To report a case of atrial fibrillation (AF) due to oral methylprednisolone.

Case Summary

A 45-year-old white man with chronic intermittent paroxysmal supraventricular tachycardia (PSVT) reacted to oral methylprednisolone by developing a PSVT episode that elicited an 18-hour episode of AF. AF was resolved by discontinuing methylprednisolone and administering oral nadolol, and no recurrence was reported for 6 years.

Discussion

This appears to be the first published report linking AF to oral methylprednisolone. Based on an analysis of the literature, it is suggested that AF may be triggered by any autonomic paroxysmal event in some individuals. Accepting the clinical evidence linking methylprednisolone to PSVT, the case is elaborated as having involved an initial atrial paroxysmal reaction to the drug, which then triggered AF.

Conclusions

Clinicians may wish to consider history of arrhythmias, and to monitor them, when prescribing oral methylprednisololne.

Atrial fibrillation associated with systemic lupus erythematosus and use of methylprednisolone

Systemic lupus erythematosus is known to have cardiac manifestations consisting of pericarditis, myocarditis, endocarditis, and coronary vasculitis. Pericarditis is the most common cardiac manifestation of systemic lupus erythematosus. Myocarditis may be suspected in patients presenting with unexplained tachycardia, conduction disturbances, unexplained systolic dysfunction with or without heart failure, or arrhythmias. The development of arrhythmias in systemic lupus erythematosus could be secondary to pericarditis, myocarditis, or ischemia caused by coronary vasculitis. The development of atrial fibrillation in systemic lupus erythematosus is not commonly reported. There have been few reports on the patients developing atrial fibrillation after being started on methylprednisolone therapy. Described here is a case of the development of atrial fibrillation in a newly diagnosed 37-year-old patient with systemic lupus erythematosus who was started on intravenous methylprednisolone therapy.