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Reversible exercise-induced advanced atrioventricular block due to cardiac sarcoidosis
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Reversible exercise-induced advanced atrioventricular block due to cardiac sarcoidosis Lothar Rössig, MD, Stefan H. Hohnloser, MD From J.W. Goethe University, Frankfurt, Germany.
Figure 1
A 32-year-old athletic man presented with impaired exercise tolerance of 5 weeks’ duration. He had a 1-year history of histologically proven cutaneous sarcoidosis without any documented systemic manifestations. Initial ECG showed sinus rhythm with first-degree atrioventricular (AV) block, incomplete right bundle branch block, and negative T waves in the precordial leads (Figure 1, top left, 25 mm/s). During exercise stress testing, AV conduction deteriorated further, resulting in 2:1 AV block and leading to exercise termination (Figure 1, top right; arrows indicate P waves). At a slightly lower heart rate during recovery from exercise, the nonconducted P wave moved out of the T wave, resulting in an identical morphology of conducted and nonconducted P waves and proving the presence of 2:1 AV block. Address reprint requests and correspondence: Dr. Lothar Rössig, Department of Internal Medicine III, J.W. Goethe University, Theodor Stern Kai 7, 60590 Frankfurt, Germany. E-mail address: roessig@em. uni-frankfurt.de.
Subsequent workup, which included cardiac catheterization and endomyocardial biopsy, confirmed the diagnosis of cardiac sarcoidosis. The patient was treated with oral methylprednisone. After 3 weeks of treatment, he reported markedly improved exercise tolerance. Repeated stress testing showed normal AV conduction during exercise at comparable workload (Figure 1, bottom right). AV conduction defects associated with cardiac sarcoidosis include first- to-third degree AV block, with complete heart block being the most common finding in 23–30% of patients. Highly symptomatic exercise-induced second-degree AV block as observed in our patient is the first advanced AV block reported to be unmasked during exercise testing in a patient with sarcoidosis. In ⬃50% of patients, AV nodal dysfunction responds to corticosteroid therapy. In our patient, 12-lead ECG monitoring of AV conduction during exercise provides an example of unusual rapid recovery of the conduction system in response to corticosteroid therapy.
1547-5271/$ -see front matter © 2007 Heart Rhythm Society. All rights reserved.
doi:10.1016/j.hrthm.2006.07.014
Reversible exercise-induced advanced atrioventricular block due to cardiac sarcoidosis Lothar Rössig, MD, Stefan H. Hohnloser, MD From J.W. Goethe University, Frankfurt, Germany.
Figure 1
A 32-year-old athletic man presented with impaired exercise tolerance of 5 weeks’ duration. He had a 1-year history of histologically proven cutaneous sarcoidosis without any documented systemic manifestations. Initial ECG showed sinus rhythm with first-degree atrioventricular (AV) block, incomplete right bundle branch block, and negative T waves in the precordial leads (Figure 1, top left, 25 mm/s). During exercise stress testing, AV conduction deteriorated further, resulting in 2:1 AV block and leading to exercise termination (Figure 1, top right; arrows indicate P waves). At a slightly lower heart rate during recovery from exercise, the nonconducted P wave moved out of the T wave, resulting in an identical morphology of conducted and nonconducted P waves and proving the presence of 2:1 AV block. Address reprint requests and correspondence: Dr. Lothar Rössig, Department of Internal Medicine III, J.W. Goethe University, Theodor Stern Kai 7, 60590 Frankfurt, Germany. E-mail address: roessig@em. uni-frankfurt.de.
Subsequent workup, which included cardiac catheterization and endomyocardial biopsy, confirmed the diagnosis of cardiac sarcoidosis. The patient was treated with oral methylprednisone. After 3 weeks of treatment, he reported markedly improved exercise tolerance. Repeated stress testing showed normal AV conduction during exercise at comparable workload (Figure 1, bottom right). AV conduction defects associated with cardiac sarcoidosis include first- to-third degree AV block, with complete heart block being the most common finding in 23–30% of patients. Highly symptomatic exercise-induced second-degree AV block as observed in our patient is the first advanced AV block reported to be unmasked during exercise testing in a patient with sarcoidosis. In ⬃50% of patients, AV nodal dysfunction responds to corticosteroid therapy. In our patient, 12-lead ECG monitoring of AV conduction during exercise provides an example of unusual rapid recovery of the conduction system in response to corticosteroid therapy.
1547-5271/$ -see front matter © 2007 Heart Rhythm Society. All rights reserved.
doi:10.1016/j.hrthm.2006.07.014