Complete heart block in lupus

Drug-Induced Complete Atrioventricular Block in an Elderly Patient: A Case Report Highlighting Digoxin-Beta Blocker Interactions and a Paradoxical State

Complete atrioventricular (AV) block is a severe conduction abnormality caused by intrinsic cardiac disease, ischemia, electrolyte imbalances, or drug interactions. Elderly patients on multiple medications are particularly vulnerable to polypharmacy-related interactions. This case report describes an 82-year-old female presenting to the emergency department with fatigue, syncope, and disorientation. Her medical history included atrial fibrillation, hypertension, and heart failure, with a medication regimen of digoxin 0.25 mg given daily 5 days out of 7, metoprolol 50 mg twice daily, lisinopril 10 mg daily, furosemide 40 mg daily, and spironolactone 50 mg daily. Clinical examination revealed bradycardia and a holosystolic murmur in the mitral valve area, while the electrocardiogram showed complete AV block at a ventricular rate of 35 bpm. Laboratory results indicated mild hyperkalemia (4.9 mmol/L). Suspecting a digoxin-beta-blocker interaction, antiarrhythmic therapy was discontinued. Within three days, the AV block resolved, transitioning to atrial fibrillation with a high ventricular rate. Bisoprolol was introduced for rate control, and hemodynamic stability was achieved. The patient was discharged with a revised medication regimen and showed no recurrence of AV block. This case emphasizes the importance of recognizing drug interactions as a reversible cause of AV block and using drug interaction checkers to manage polypharmacy, especially in elderly patients with multiple comorbidities. It also highlights the rare and paradoxical combination of atrial flutter and complete AV block.

Systemic Diseases and Heart Block

Systemic diseases can cause heart block owing to the involvement of the myocardium and thereby the conduction system. Younger patients (<60) with heart block should be evaluated for an underlying systemic disease. These disorders are classified into infiltrative, rheumatologic, endocrine, and hereditary neuromuscular degenerative diseases. Cardiac amyloidosis owing to amyloid fibrils and cardiac sarcoidosis owing to noncaseating granulomas can infiltrate the conduction system leading to heart block. Accelerated atherosclerosis, vasculitis, myocarditis, and interstitial inflammation contribute to heart block in rheumatologic disorders. Myotonic, Becker, and Duchenne muscular dystrophies are neuromuscular diseases involving the myocardium skeletal muscles and can cause heart block.

Systemic Diseases and Heart Block

Systemic diseases can cause heart block owing to the involvement of the myocardium and thereby the conduction system. Younger patients (<60) with heart block should be evaluated for an underlying systemic disease. These disorders are classified into infiltrative, rheumatologic, endocrine, and hereditary neuromuscular degenerative diseases. Cardiac amyloidosis owing to amyloid fibrils and cardiac sarcoidosis owing to noncaseating granulomas can infiltrate the conduction system leading to heart block. Accelerated atherosclerosis, vasculitis, myocarditis, and interstitial inflammation contribute to heart block in rheumatologic disorders. Myotonic, Becker, and Duchenne muscular dystrophies are neuromuscular diseases involving the myocardium skeletal muscles and can cause heart block.

Management of Complete Heart Block in a Pregnant Woman with Systemic Lupus Erythematosus-Associated Complications: Treatment Considerations and Pitfalls

We present a case of a pregnant woman with systemic lupus erythematosus (SLE) who was diagnosed with asymptomatic complete heart block (CHB) during pregnancy. To evaluate possible risks and benefits of pacemaker (PM) implantation, a multidisciplinary counselling board was held. Its recommendation was to perform PM implantation to prevent intra-uterine growth restriction from insufficient cardiac output using a fluoroscopic protective shield. The procedure was performed without complications and established permanent pacing on onwards ECG examinations. The patient subsequently gave birth to a healthy newborn. After a retrospective clinical case evaluation and review of relevant literature, a presumptive association between CHB and the primary diagnosis was proposed. Above that, pregnant women with SLE who develop hypertension are commonly treated with methyldopa, which may cause conduction abnormalities. Clinical recommendations for young female patients expecting pregnancy are lacking in this area. Careful diagnostic and treatment approaches should be used in the management of possible SLE-related complications in women of child-bearing age, focusing on preventable events.

Unusual Presentations of Systemic Lupus Erythematosus: A Narrative Review

Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune disease characterized by an almost 10:1 female predominance, the presence of deleterious nuclear autoantibodies, a tendency for flare, and striking protean manifestations. Early diagnosis is associated with less damage accrual, lower costs, and improved quality of life due to timely treatment. However, early disease may not uncommonly show nonspecific presentation, a single classification criterion, or an unusual organ involvement contributing to frequent, often substantial diagnostic delays. We reviewed the literature (1982-2022) to accumulate and classify all reports of rare, atypical, and unusual presentations. These can involve almost every organ and system, and thus, present to physicians in every discipline and setting. Increasing physicians' awareness of the potential of occult SLE to appear in varied, diverse, and unexpected presentations, may encourage the inclusion of SLE in the differential. Informed history and examination focusing on systemic and joint symptoms and mucocutaneous involvement, and basic tests (focusing on leukopenia, thrombocytopenia, and proteinuria; followed by antinuclear antibodies and complement levels) will correctly diagnose most patients on presentation or within the following months and enable timely treatment.

Assessment of Cardiac Risk in Women with Autoimmune Disease

PURPOSE OF REVIEW

The purpose of our review was to evaluate current standards in clinical practice in determining overall cardiac risk in female patients with chronic rheumatologic diseases. We hoped to not only summarize known cardiac manifestations of various chronic rheumatologic diseases but also determine the effectiveness of new risk scores in determining cardiac risk in this patient population.

RECENT FINDINGS

Chronic rheumatologic diseases have been associated with various cardiac manifestations for some time, with initial studies involving risk of coronary artery disease (CAD) in rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). However, recent studies have shown numerous other cardiac manifestations associated with these and other chronic rheumatologic diseases. Risk scores have been used for several decades to help determine overall cardiac risk in the general population, but these risk scores have notoriously underestimated the risk of cardiac disease in woman and in patients with chronic rheumatologic diseases. These diseases, often with a female predominance, can impact long-term mortality and have devastating consequences if not monitored and treated appropriately. Thus, new risk scores have been developed over the last several years to help improve detection and awareness of cardiac disease in these patients. Novel modified risk scores have found some success at improving the detection of cardiac disease in patients with chronic rheumatologic diseases. Further studies looking at these risk scores need to determine the accuracy of these scores and where they fall short. With the advent of advanced imaging technologies, future risk scores may involve certain imaging-based markers to help guide accurate risk determination.

Systemic Diseases and Heart Block

Systemic diseases can cause heart block owing to the involvement of the myocardium and thereby the conduction system. Younger patients (<60) with heart block should be evaluated for an underlying systemic disease. These disorders are classified into infiltrative, rheumatologic, endocrine, and hereditary neuromuscular degenerative diseases. Cardiac amyloidosis owing to amyloid fibrils and cardiac sarcoidosis owing to noncaseating granulomas can infiltrate the conduction system leading to heart block. Accelerated atherosclerosis, vasculitis, myocarditis, and interstitial inflammation contribute to heart block in rheumatologic disorders. Myotonic, Becker, and Duchenne muscular dystrophies are neuromuscular diseases involving the myocardium skeletal muscles and can cause heart block.