A 63 yo female was referred from an outside hospital with a right subtrochanteric femur fracture after a mechanical fall. Preoperative cardiac evaluation was requested. Her EKG showed a PR interval of 390 ms, RBBB, and LAFB. She had no presyncope or syncope but had noted exertional dyspnea in the preceding two months when walking on an incline. The RBBB was newly noted 12 months PTA, at which time the PR interval was 160 ms and occasional PVCs were present. A nuclear ETT and echocardiogram were normal; ASA 81 mg was prescribed.
The consulting hospitalist recommended proceeding with surgery with intra and postoperative telemetry. The patient underwent an uncomplicated intramedullary fixation of her fracture. No bradycardia was noted; however, frequent multifocal PVCs were present. Chest X‐ray and Lyme antibody testing were negative. Because of the accelerated progression over the prior year of the conduction disease and ventricular ectopy cardiology consultation was obtained.
Evaluation for a cardiomyopathy was recommended. Cardiac MRI showed diffuse late gadolinium enhancement consistent with an infiltrative process such as sarcoidosis or post‐myocarditis fibrosis. The MRI localizer images suggested hilar adenopathy which was confirmed on chest CT. A medistinal lymph node biopsy showed non‐caseating granulomata. Prednisone therapy was begun with normalization of the PR interval. However, Holter monitoring on prednisone showed persistent multifocal PVCs and NSVT. An ICD was placed; the patient remains clinically well at this time.
This case is presented to highlight three clinical aspects of cardiac sarcoidosis (CS). First, as many as 1/3 of patients have no obvious extracardiac disease at presentation. The patient’s mediastinal adenopathy was absent on CXR but serendipitously noted on cardiac MRI. Second, CS frequently presents with heart block without CHF, particularly in younger patients. Third, ventricular arrythmias do not routinely respond to corticosteroid therapy and are associated with sudden cardiac death (SCD) in 25‐65% of CS patients. The roles of advanced imaging, EP evaluation, and AICD placement in identifying and treating patients at high risk for SCD are still being defined. The case also shows the critical role played by consulting hospitalists in advancing the care of non‐medical patients. Although the patient’s cardiac issues did not preclude surgery her expedited evaluation led to the timely diagnosis and treatment of a serious illness.
Consulting hospitalists performing pre‐operative evaluations bring added value to their role by identifying and coordinating post‐operative management of substantive medical issues that do not preclude surgery. In this case, the rapid evolution of conduction disturbances and ventricular arrythmias in a relatively young patient was atypical for degenerative conduction system disease (Lev’s disease) and prompted expedited evaluation.
To cite this abstract:Blair R. A Skip Before a Fall. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 350. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/a-skip-before-a-fall/. Accessed March 28, 2020.