Asymptomatic Bradycardia Research Articles

Lacosamide Boluses Decreased Seizure Burden and Were Well Tolerated in Neonates With Acute Seizures: A Single-Center Retrospective Case Series.

Introduction: Neonatal seizures are associated with worsened neurodevelopmental outcomes. Phenobarbital, the only US Food and Drug Administration (FDA)-approved treatment for neonatal seizures, can cause neuronal apoptosis and may worsen neurodevelopmental outcomes. Lacosamide may be an efficacious treatment for neonatal seizures. Methods: We assessed the impact of lacosamide boluses on seizure burden in a retrospective cohort of 15 neonates monitored with video electroencephalography (EEG). Medication bolus times and seizure start/end times on EEG tracings determined change in seizure burden. Results: Seven patients received lacosamide as first- or second-line treatment and 8 as third-line or later. Average 4-hour seizure burden decreased from 13% to 3% following lacosamide boluses (P = .002). Reduction in seizure burden greater than 30% followed 79% of boluses. Lacosamide was well tolerated; one patient experienced mild asymptomatic episodic bradycardia that medication taper resolved. Conclusions: Lacosamide significantly decreased seizure burden in this cohort. Prospective studies of lacosamide treatment for neonatal seizures are warranted.

Effectiveness of a Triple Antiarrhythmic Drug Strategy for Arrhythmia Recurrence after Persistent Atrial Fibrillation Ablation.

Treating recurrent atrial arrhythmias after persistent atrial fibrillation (PeAF) ablation is often challenging. This single-center, prospective study aimed to observe the effectiveness of different combinations of oral antiarrhythmic drugs (AADs) in reverting to sinus rhythm (SR) in patients with recurrent atrial arrhythmias after PeAF ablation. Forty-five patients who experienced recurrent atrial arrhythmias after PeAF ablation were included. Based on their medication regimens, patients were divided into two groups, with the study group being a triple-drug group (digoxin combined with amiodarone/ propafenone and β-blocker), and the control group being a non-triple-drug group. The rate of reversion to SR was significantly higher in the study group (n = 29) than in the control group (n = 16) at 3 weeks (34.48% vs. 0%, p<0.01) and 1 month (44.84% vs. 6.25%, p = 0.02) after initiating AADs. No patients with asymptomatic bradycardia were observed in either group. For patients with recurrent atrial arrhythmias after PeAF ablation, a regimen of low-dose digoxin combined with amiodarone/propafenone and β-blocker may effectively improve short-term reversion rates.

Management of complete heart block detected during labor: A case report

Complete heart block in women of childbearing age is rare, and incidental diagnosis during pregnancy is more uncommon. Hence, there remain no well-established guidelines on the management of patients with complete heart block presenting in labor. Here, we present a 26-year-old full-term primigravida, with no known previous cardiac history, in active labor with asymptomatic bradycardia in the 30–40s unresponsive to atropine augmentation. After multidisciplinary consultation, the decision was to proceed with delivery as planned without indication for a temporary pacemaker. The patient successfully delivered a full-term infant via operative vaginal delivery, with an ensuing cardiac workup completed postpartum.

Safety and clinical activity of BMS-986365 (CC-94676), a dual androgen receptor ligand-directed degrader and antagonist, in heavily pretreated patients with metastatic castration-resistant prostate cancer

Metastatic castration-resistant prostate cancer (mCRPC) that progresses on androgen receptor pathway inhibitors (ARPIs) may continue to be driven by AR signaling. BMS-986365 is an orally administered ligand-directed degrader targeting the AR via a first-in-class dual mechanism of AR degradation and antagonism. CC-94676-PCA-001 (NCT04428788) is a phase I multicenter study of BMS-986365 in patients with progressive mCRPC. Patients who progressed on androgen deprivation therapy, one or more ARPIs, and taxane chemotherapy (unless declined/ineligible) were enrolled. The study included dose escalation (part A) and expansion (part B) of BMS-986365 up to 900 mg twice daily. Primary objectives were safety and tolerability, and to define maximum tolerated dose and/or recommended phase II dose. Key secondary endpoints included decline in prostate-specific antigen ≥50% (PSA50) and radiographic progression-free survival (rPFS). Parts A and B enrolled 27 and 68 patients, respectively. In part B, the median number of prior therapies was 4 (range 2-11). The most common treatment-related adverse events were asymptomatic prolonged corrected QT interval (47%) and bradycardia (34%). Part A maximum tolerated dose was not reached and recommended phase II dose selection is ongoing. Across part B three highest doses (400-900 mg twice daily, n= 60), PSA50 was 32% (n= 19), including 50% (n= 10/20) at 900 mg; median rPFS (95% confidence interval) was 6.3 months (5.3-12.6 months), including 8.3 months (3.8-16.6 months) at 900 mg; and rPFS was longer in patients without versus with prior chemotherapy: 16.5 months (5.5 months-not evaluable) versus 5.5 months (2.7-8.3 months), respectively. Efficacy was observed in patients with mCRPC with AR ligand binding domain (LBD) WT or with AR LBD mutations. BMS-986365 was well tolerated, with a manageable safety profile, and demonstrated activity in heavily pretreated patients with mCRPC with potentially higher benefit in chemotherapy-naive patients. These data show the potential of BMS-986365 to overcome resistance to current ARPIs, regardless of AR LBD mutation status.

The CARDIAC MANIFESTATION IN DENGUE INFECTION

ABSTRACT Introduction: Dengue infection rarely affects the heart, but clinical symptoms of cardiac involvement may range greatly from a silent illness to severe myocarditis resulting in death. With the increasing incidence of dengue fever, reports of atypical manifestations are on the rise, these may be underreported because of a lack of awareness and underdiagnosed Cases: A 40-year-old man presents with acute fever for three days with positive non-structural protein 1 (NS1) and asymptomatic bradycardia. ECG revealed sinus rhythm (40 bpm) with an absence of ST-segment elevation. His laboratory examination showed a rise in NT-Pro BNP and CKMB levels. Echocardiography showed hyperechogenic myocardium suspicious for myocarditis, with a left ventricle ejection fraction (LVEF) of 73% and no systolic, diastolic, or valve abnormalities. The patient recovered without further complications and was discharged home. Conclusion: Cardiac involvement is uncommon and encountered in centres which handle large numbers of patients with dengue infection. Clinical manifestations of cardiac involvement in dengue infection can vary widely, from an incidental finding to severe cardiac failure resulting in death. Keywords: bradycardia; dengue infection; myocarditis; NS1

COmbination of Targeted temperature management and Thrombectomy after acute Ischemic Stroke (COTTIS): a pilot study

BackgroundTo evaluate the feasibility and safety of a fast initiation of cooling to a target temperature of 35°C by means of transnasal cooling in patients with anterior circulation large vessel...

Pulse methylprednisolone therapy triggered sinus bradycardia in two children

Intravenous methylprednisolone is an important therapeutic modality in many conditions, owing to their anti-inflammatory and immune-modulating properties. Along with other side-effects of corticosteroids, cardiovascular side-effects are also seen in varying degree in children. Sinus bradycardia is reported uncommonly in children following high dose intravenous methylprednisolone. We report two paediatric cases without any underlying cardiac problems with asymptomatic bradycardia following high dose intravenous methylprednisolone. Heart rate reduction was seen from 30-40% compared to the baseline heart rate, which returned to its normal value after 24-36 hours of stoppage of the offending drug. A high index of suspicion along with strict cardiovascular monitoring is necessary in patients receiving high dose of methylprednisolone.

Safety of outpatient commencement of sotalol

Inpatient monitoring is recommended for sotalol initiation. The purpose of this study was to assess the safety of outpatient sotalol commencement. This is a multicenter, retrospective, observational study of patients initiated on sotalol in an outpatient setting. Serial electrocardiogram monitoring at day 3, day 7, 1 month, and subsequently as clinically indicated was performed. Corrected QT (QTc) interval and clinical events were evaluated. Between 2008 and 2023, 880 consecutive patients who were commenced on sotalol were evaluated. Indications were atrial fibrillation/flutter in 87.3% (n = 768), ventricular arrhythmias in 9.9% (n = 87), and other arrhythmias in 2.8% (n = 25). The daily dosage at initiation was 131.0 ± 53.2 mg/d. The QTc interval increased from baseline (431 ± 32 ms) to 444 ± 37 ms (day 3) and 440 ± 33 ms (day 7) after sotalol initiation (P < .001). Within the first week, QTc prolongation led to the discontinuation of sotalol in 4 and dose reduction in 1. No ventricular arrhythmia, syncope, or death was observed during the first week. Dose reduction due to asymptomatic bradycardia occurred in 3 and discontinuation due to dyspnea in 3 within the first week. Overall, 1.1% developed QTc prolongation (>500 ms/>25% from baseline); 4 within 3 days, 1 within 1 week, 4 within 60 days, and 1 after >3 years. Discontinuation of sotalol due to other adverse effects occurred in 41 patients within the first month of therapy. Sotalol initiation in an outpatient setting with protocolized follow-up is safe, with no recorded sotalol-related mortality, ventricular arrhythmias, or syncope. There was a low incidence of significant QTc prolongation necessitating discontinuation within the first month of treatment. Importantly, we observed a small incidence of late QT prolongation, highlighting the need for vigilant outpatient surveillance of individuals on sotalol.

A Systematic Review and Meta-Analysis of Randomised Controlled Trials Assessing Clinical and Haemodynamic Outcomes of Ivabradine in Heart Failure With Reduced Ejection Fraction Patients

Ivabradine, a pure bradycardic agent, can be given to heart failure reduced ejection fraction (HFrEF) patients with a sinus rhythm of ≥70 bpm on a maximum beta blocker dose, or when beta blockers are contraindicated. This study aimed to see how ivabradine affects the clinical and haemodynamic outcomes of HFrEF patients. This systematic review and meta-analysis searched ClinicalTrials.gov, OpenMD, ProQuest, PubMed, and ScienceDirect for potential articles. All relevant data were extracted. For all pooled effects, the random effect model was applied. A total of 18,972 heart failure (HF) patients from nine randomised clinical trials (RCTs) were involved in this study. Ivabradine decreased the risk of HF mortality (RR 0.79; 95% CI 0.64-0.98; p=0.03) and HF hospitalisation (RR 0.80; 95% CI 0.65-0.97; p=0.03). Ivabradine was related to a greater reduction in heart rate (MD -12.21; 95% CI -15.47 - -8.96; p<0.01) and left ventricular ejection fraction (LVEF) improvement (MD 3.24; 95% CI 2.17-4.31; p <0.01) compared with placebo. Asymptomatic bradycardia (RR 4.25; 95% CI 3.36-5.39; p<0.01) and symptomatic bradycardia (RR 3.99; 95% CI 3.17-5.03; p<0.01) were higher in the ivabradine group. Ivabradine can reduce the risk of HF mortality and HF hospitalisation in HFrEF patients. Ivabradine also effectively reduces resting heart rate and improves LVEF. However, ivabradine is associated with a greater risk of symptomatic and asymptomatic bradycardia.

High Dose Cytosine Arabinoside- Induced Asymptomatic Bradycardia A Rare Case of Concurrent Pneumoretroperitoneum, Pneumomediastinum, Pneumothorax and Subcutaneous Emphysema Seen After Colonoscopy

Coexistence of pneumoretroperitoneum, pneumomediastinum, pneumothorax and subcutaneous emphysema after colonoscopy is a rarely seen condition. We present this rare clinical condition seen after colonoscopy to contribute to the literature. A 62-year-old male patient, who was operated for acute abdomen two years ago, underwent colonoscopy due to colon stenosis. He applied with the complaints of swelling in the neck and subcutaneous swelling in the chest and abdomen after the procedure. Pneumoretroperitoneum, pneumomediastinum and subcutaneous emphysema were detected in the patient In case of subcutaneous emphysema to be seen after colonoscopy, the possibility of pneumomediastinum and pneumothorax should also be considered.

High Dose Cytosine Arabinoside- Induced Asymptomatic Bradycardia

Cytosine Arabinoside (Cytarabine) is commonly used agents in acute myeloid leukemia (AML). Cardiovascular side effects are not common during treatment. We aimed to present asymptomatic bradycardia developed during the first consolidation treatment in a patient with acute myeloid leukemia. A 34-year-old male patient was diagnosed with AML in February. After induction chemotherapy, high dose cytarabine treatment was started at 2x1.5 grams/m² for consolidation treatment. On the 11th day of the treatment, his pulse decreased to 39 beats/min. On the 12th day after the initiation of high dose cytosine arabinoside treatment (6 days after chemotherapy treatment ends), the patient's pulse rate was above 50/min, and there was no bradycardia in the following days. Other causes of other causes of bradycardia were excluded. It was reported that the patient had sinus bradycardia with an ejection fraction of 65% and his heart rate was rhythmic. There are seven patients with acute myeloid leukemia, one patient with acute lymphoblastic leukemia, one patient with non-Hodgkin's lymphoma, and one patient with Hodgkin's lymphoma who reported high dose cytosine arabinoside associated bradycardia. In addition, one patient with acute myeloid leukemia developed bradycardia with low dose cytosine arabinoside. Our case is the 11th case in the literature that develops bradycardia due to cytarabine.

Abstract 18597: Is Sleep Disordered Breathing Optimized in Patients With Bradycardic Rhythm Disorders Prior to Pacemaker Implantation? - A Retrospective Observational Study and a Quality Improvement Project

Introduction: Obstructive sleep apnea (OSA) is associated with cardiovascular (CV) morbidity and mortality ranging from asymptomatic bradycardia to sudden death. Studies have shown that sleep-related bradyarrhythmias, decrease with continuous positive airway pressure (CPAP) and are unlikely to develop symptomatic bradycardia in the long-term. AHA/ACC/HRS recommends to evaluate and treat suspected or documented conduction disorder during sleep including patients who have received or are being considered for permanent pacemaker (PPM). Objective We aim to examine the number of sleep studies and CPAP performed and address the barriers of under-diagnosis and treatment with post intervention quality improvement initiative. Methods: We performed retrospective analysis of patients &gt;18 years admitted for elective PPM placement from 01/10/2021-01/01/2023. Categorical variables were reported as number and percent and numerical variable was reported as mean. Multiple logistic regression was used to identify predictors for compliance and sleep study prescription. All statistical analyses were performed with SAS software, version 9.4. Results Of 423 patients, mean age was 78.1 years, 56.50% were males, 96.9% were Caucasians and mean BMI was 30.1 kg/m 2 . Only 34.75 % (N= 147/423) received sleep study. 93.2% (N=137/147) were diagnosed with OSA and 82.9% (N=122/137) were treated with CPAP. Only 63.1% were compliant with CPAP. Males were more complaint with CPAP [OR 3.13 (95% CI 1.36-7.18, p=0.0072)]. Mean BMI at OSA diagnosis was 33.7 kg/m 2 and 30.1 kg/m 2 at PPM implantation. Weight loss was noted but most patients remained obese. Males, age ≥80 and obesity were significant predictors to get sleep study. After study outcomes, we adopted a standardized algorithm for risk assessment, incorporated EHR reminder and educated doctors. The intervention is currently ongoing. Conclusion Data on underutilization of sleep study helped us to work with administration to produce a protocol for screening high risk patients. Treating sleep apnea not only alleviates apnea-related symptoms but also improves CV outcome by avoiding unnecessary pacemaker implantation and minimizing unnecessary health care cost. If effective, this strategy can be a model for other hospitals.

Abstract 14394: Complete Atrioventricular Block in a Young Patient With Alport Syndrome: A Case Report

Background: Atrioventricular block (AVB) in young adults is rare, and the etiologies and mechanisms in most cases remain uncertain. Alport syndrome is a heterogeneous, hereditary disorder characterized by nephropathy, hearing loss, and ocular abnormalities. Complete AVB has never been reported in Alport syndrome patients with normal kidney function. Case report: A 20-year-old male patient was admitted to hospital with “asymptomatic bradycardia for years”. On admission, the patient’s blood pressure was normal and electrocardiogram (ECG) showed third-degree AVB with atrial rate of 63 bpm and ventricular rate of 36 bpm. He was diagnosed with Alport syndrome at the age of 10. Genetic testing at that time showed single nucleotide variants (c.2372T&gt;C, c.2072T&gt;G) and deletion (c.1781-1949(Exon25)) in COL4A5 gene. During the subsequent 10-year follow-up, the patient was presented with consistent hematuria and proteinuria, but his renal function has never been found impaired. He denied other medical history as well as family history of arrhythmia. Laboratory tests indicated hypoproteinemia, hyperuricemia, hyperlipidemia, and hyperhomocysteinemia. The 24-hour ambulatory ECG revealed a heart rhythm consisting of sinus rhythm with second-degree AVB (2:1 downward transmission) and complete AVB with junctional escape. The mean ventricular rate was 36 bpm (ranged 25-60 bpm). Neither echocardiography nor cardiac magnetic imaging with delayed gadolinium enhancement found any significant abnormality. We then did whole exome sequencing (WES), which did not identify specific pathogenic variant (Table1). 3mg atropine was admitted to the patient for an atropine test to rule out the possibility of vagally mediated AVB and the pacemaker implantation was then performed. Conclusion: We report a case of complete AVB with unknown etiology in a young patient with Alport syndrome.

Ophthalmic Atropine: A Typical Anticholinergic Toxidrome From an Atypical Old Culprit.

Included on the World Health Organization Model Lists of Essential Medicines, atropine remains a cornerstone medication that is used for a myriad of clinical indications. Systemically, atropine carries indications for the treatment of asymptomatic and symptomatic bradycardia, reduction of salivation and bronchial secretions prior to surgery, and as an antidote for a variety of poisoning agents (i.e., carbamate or organophosphate insecticides, nerve agents, muscarine-containing mushrooms). Topically, atropine is administered via the ophthalmic route for the treatment of cycloplegia, mydriasis, and amblyopia or may be administered sublingually to treat chronic sialorrhea. As an anticholinergic, supratherapeutic concentrations of atropine result in a toxidrome typical of other anticholinergic medication overdoses. However, it is easy to overlook atropine as the causative agent when being administered topically, potentially resulting in an unnecessarily extensive and complicated workup. This case report describes the systemic absorption of atropine administered through the ophthalmic route at normal doses, resulting in stroke-like symptoms in an adolescent male. Upon identifying that the patient was being treated with atropine ophthalmic drops prior to hospital arrival, a dose of intravenous physostigmine was administered, resulting in complete reversal of all toxidrome symptoms.

Asymptomatic bradycardia as a manifestation of intermediate high-risk pulmonary embolism

Progressively worsening dyspnea as an initial manifestation of an intermediate high-risk pulmonary embolism (PE) is a readily reported life-threatening cardiac emergency. Atypical presentation of PE may make the initial diagnosis challenging and is often the reason it is missed by clinicians. A 60-year-old woman with asymptomatic bradycardia presented with shortness of breath and dizziness. On examination, she was noted to have a heart rate of 40 beats per minute (bpm) which slightly improved to 55 bpm after intravenous (IV) fluids were administered. A transthoracic echocardiogram (TTE) showed evidence of severe right ventricular strain. Chest computed tomography angiogram (CTA) confirmed PE. After percutaneous aspiration thrombectomy, she was transitioned to direct oral anticoagulant (DOAC) from a heparin infusion and discharged on oral anticoagulation. Notably, her hospital course was marked by labile cycles between normotension and hypertension, with blood pressures exceeding 200/100 mmHg. The possibility that hypertensive states may prevent hemodynamic deterioration and a resulting high-risk pulmonary embolism is considered in patients presenting with multiple risk factors for thromboembolism.

Efficacy and safety of bisoprolol 5 mg plus amlodipine 5 mg in patients with hypertension uncontrolled on monotherapy with 5 mg of amlodipine, a phase III multicenter, randomized, double-blind, placebo-controlled clinical trial – the AMCOR study

Objective To evaluate the antihypertensive effect and safety of bisoprolol 5 mg (BISO5mg) and amlodipine 5 mg (AMLO5mg) combination in comparison to AMLO5mg in hypertensive subjects uncontrolled with AMLO5mg. Methods Phase III, prospective, randomized, double-blind, placebo-controlled, 8-week trial with parallel design (EudraCT Number: 2019-000751-13). Results 367 patients aged 57.58 ± 14.62 years were randomized to BISO5mg once daily on top of AMLO5mg (n = 181) or placebo on top of AMLO5mg (n = 186). Systolic/diastolic blood pressure (SBP/DBP) in the bisoprolol-treated group was reduced by 7.2 ± 12.74/3.95 ± 8.85 mmHg at 4 weeks (both p < .0001) and by 5.5 ± 12.44/3.84 ± 9.46 mmHg at 8 weeks (p < .0001/p < .0002) compared to placebo control. Bisoprolol-treated group had lower heart rate than placebo control (difference −7.23 ± 9.84/−6.25 ± 9.26 beats per minute at 4 and 8 weeks, respectively, both p < .0001). Both target SBP and DBP was achieved at 4 weeks by 62 vs. 41% (p = .0002) and at 8 weeks by 65 vs. 46% (p = .0004) of bisoprolol-treated patients and placebo group patients, respectively. SBP <140 mmHg was achieved at 4 and 8 weeks in 68 and 69% of bisoprolol-treated patients and 45 and 50% of placebo group patients, respectively. No deaths and serious adverse events were reported. Adverse events occurred in 34 bisoprolol-treated patients vs. 22 patients in the placebo group (p = .064). Bisoprolol was withdrawn due to adverse events in 7 patients, mostly (n = 4) due to asymptomatic bradycardia. Conclusions Addition of bisoprolol to patients uncontrolled with amlodipine monotherapy significantly improves blood pressure control. We can expect additional 7.2/3.95 mmHg SBP/DBP lowering effect by adding bisoprolol 5 mg to amlodipine 5 mg.

P325 CARDIAC SARCOIDOSIS PRESENTING WITH ATRIOVENTRICULAR BLOCK AND SUBSEQUENT CARDIAC ARREST: A CASE REPORT

Abstract A 53–year–old male patient with no significant past medical history and no familiar history for cardiac diseases presented to the emergency department for asymptomatic bradycardia. The ECG showed complete atrioventricular block in the absence of pathological findings on the echocardiogram and no coronary lesions were found on coronary angiography. The patient underwent pacemaker (PM) implantation. A few months later the patient suffered from cardiac arrest in sustained ventricular tachycardia, effectively treated with DC shock. The echocardiogram showed mild right ventricular dilation and dysfunction with regional wall motion abnormalities, especially in the subtricuspid site. Cardiac magnetic resonance imaging (MRI) showed focal areas of delayed enhancement with a non–ischaemic pattern and distribution with a hook sign, highly suggestive of cardiac sarcoidosis. FDG PET showed cardiac, hepatic, splenic, and lymph nodal uptake. In the suspicion of systemic sarcoidosis, an hepatic biopsy was performed, being the liver the most accessible site. The histological examination showed the presence of non–caseating granulomas. Therefore, a diagnosis of Systemic Sarcoidosis (SS) with Cardiac involvement was made and the PM was upgraded to CRT–D in secondary prevention. The patient was discharged with cortisone therapy. Three months after discharge, a new total body PET–CT scan was performed and showed, in comparison to the previous one, the absence of areas of significant hypermetabolism in the cardiac, hepatic and bone fields. Cardiac sarcoidosis (CS) is a rare inflammatory granulomatous myocardial disease of unknown etiology that should be suspected in young patients with atrioventricular conduction disturbances and complex ventricular arrhythmias. The diagnostic approach is challenging: imaging techniques (MRI, PET) can be suggestive of CS but biopsy with histological demonstration of the non–caseous granuloma is mandatory. Endomyocardial biopsy (which has suboptimal sensitivity due to focal lesion) could be avoided if there is a more accessible and less invasive extracardiac site for biopsy. Early diagnosis relies on multidisciplinary collaboration and is essential for staging and long–term management of the disease and prevention of sudden cardiac death. Cortisone therapy remains the mainstay of treatment.

Fingolimod-related atrioventricular block in paediatric age group with multiple sclerosis: two case reports.

Multiple sclerosis is a chronic inflammatory and demyelinating disease of the central nervous system, usually seen in young adults. Early onset of multiple sclerosis at age younger than 18 years is called paediatric multiple sclerosis. Unlike adult multiple sclerosis, paediatric multiple sclerosis causes morbidity at earlier ages and often progresses in a relapsing-remitting form. Although fingolimod is an effective drug used as a disease-modifiying therapy agent in relapsing-remitting paediatric multiple sclerosis patients, it can cause dysryhthmia in the early period after first dose. Our first case is a 14-year-old girl with relapsing-remitting paediatric multiple sclerosis patients who was started to take fingolimod treatment. In the fifth hour of the follow-up, asymptomatic bradycardia was seen and the electrocardiogram was consistent with first-degree atrioventricular block. Her rhythm got spontaneously normal after 12 hours. Second case was 13 years old girl. Steroid treatment was started after her first paediatric multiple sclerosis attack. Despite treatment, she had a second attack 2 weeks after the first attack. Therefore, the neurologist switched to fingolimod therapy. Second-degree atrioventriculer block developed after 4 hours from the initiation of therapy. After 8 hours, rhythm regressed to first-degree atrioventricular block then returned to normal up to 13th hours of follow up. The aim of this article is to draw attention to dysrhythmia side effect of fingolimod which can be fatal. Therefore, the clinician must take precautions. Close cardiac rhythm monitoring is mandatory after the initiation fingolimod theraphy.

PO-05-238 BRASH SYNDROME: A RARE BUT REVERSIBLE CAUSE OF SINUS NODE DYSFUNCTION

Brash syndrome consists of a constellation of symptoms including bradycardia, renal failure, AV nodal blocking medicarions, shock, and hyperkalemia. The pathophysiology comprises of synergistic effects of AV nodal blockers and renal dysfunction with electrolyte abnormalities escalating the effect of AV nodal blockade. As a result, this syndrome is more prevalent in patients with cardiac and renal related comorbidities including end stage renal disease and hypertension requiring AV nodal blockers for treatment. Patients presenting with brash syndrome can develop a wide range of clinical symptoms from asymptomatic bradycardia to cardiogenic shock. Brash syndrome is critical to recognize because if left untreated it can lead to life threatening complications multiorgan failure and death. We present a case of a 57-year-old female with past medical history of CAD s/p PCI, HFpEF with grade 2 diastolic dysfunction, hypertension, hyperlipidemia, diabetes, asthma, ESRD on hemodialysis with frequent admissions for recurrent bradycardic episodes associated with missed hemodialysis sessions who presented to the emergency department with complaints of weakness, nausea, vomiting and multiple syncopal episodes. The patient was found to be hypotensive and bradycardic on admission for which dopamine drip was initialed. The EKG revealed sinus arrest with a junctional escape rythm at 33 beats/minute. The lab work was significant for hyperkalemia for which urgent hemodialysis was performed. The patient's home medication included carvedilol which was discontinued. Several attempts to wean off dopamine during the first 24 hrs were unsuccessful due to perisistent hypotension and bradycardia. The patient was monitored in the ICU for 48hrs on the dopamine drip after which it was successfly weaned off and patient mantained normal sinus rhythm. n/a n/a Brash syndrome is a rare cause of transient, reversible sinus node dysfucntion and bradycardia. Management involves early diagnosis, hemodyncamic support, discontinuation of AV nodal blocking agents. It is important to monitor the patient for 24-48 hrs after potassium correction as the sinus node recovery may not be immediate. Permamnent pacemaker placement should be avoided as this condition is reversible.

Clinical Characteristics and Mid-term Follow-up in Children with Isolated Complete Atrioventricular Block.

Isolated complete atrioventricular block is a rare disease often associated with maternal autoantibodies. This study aimed to present the midterm data of patients at our clinic diagnosed with isolated complete atrioventricular block. We evaluated 108 patients diagnosed with isolated complete atrioventricular block. Demographic data of the patients, electrocardiography, echocardiography, 24-hour Holter monitoring data, and follow-up and complications of the patients who underwent pacemaker implantation were evaluated retrospectively. The mean age of the patients at diagnosis was 5.51 ± 5.05 years. At the time of diagnosis, 74.8% of the patients had no symptoms associated with complete atrioventricular block. The most common symptom was fatigue. Pacemaker implantation was needed in 88 (81.4%) patients during follow-up. Significant bradycardia was the most common pacemaker implantation indication. The mean battery life was 5.41 ± 2.65 years. The battery replacement-free period of 68 patients who underwent pacemaker implantation and continued their follow-up was 4.18 ± 2.89 (0.1-10) years. Pacemaker-related complications developed in 8 patients during follow-up. Left ventricular dysfunction developed (dyssynchrony induced) in 3 patients at follow-up, and all were paced from the right ventricular anterior wall. Those patients underwent cardiac resynchronization therapy and their left ventricular dysfunction improved. Isolated complete atrioventricular block is a rare disease requiring careful clinical follow-up. Patients are often asymptomatic and significant bradycardia is the most common indication for pacemaker implantation. Left ventricular dysfunction is an important cause of morbidity, especially in patients with right ventricular anterior wall pacing. Physicians should be aware of left ventricular dysfunction during follow-up. Cardiac resynchronization therapy should be considered as a treatment option for left ventricular dysfunction.