VCOM Louisiana Research Day Program Book 2024

Case Studies

Tyson Hillock, OMS-III; Yaroslav Zuyev, OMS-III; Dr Mahesh Thapa, MD VCOM-Louisiana; St. Francis Medical Center 48 SUPRAVENTRICULAR TACHYCARDIA: A UNIQUE PRESENTATION OF ANCA VASCULITIS

Background: Antineutrophilic cytoplasmic antibody associated vasculitides (AAV) are rare autoimmune diseases causing vascular inflammation consisting of three main diseases: granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA), and microscopic polyangiitis (MPA). With a global prevalence of 10 to 20 cases per million, AAV most commonly affect the upper and lower respiratory system or kidneys. AAV has been reported to have an increased risk of hypertension (HTN), coronary artery disease (CAD), myocardial infarction, and cerebrovascular disease. Less than 10% of primary vasculitides have shown direct involvement in cardiac function with the most common of AAV to be EGPA. Atrial Fibrillation (AF) is the most reported arrhythmia in AAV cardiac disease. Here we present a rare hemodynamically unstable case of AAV with supraventricular tachycardia (SVT) rather than AF, a symptom not before reported in AAV. Methods: A 74-year-old male with pertinent past medical history of Hyperlipidemia (HLD), HTN, CAD status post percutaneous interventions with two stents placed on carvedilol 12.5mg and clopidogrel 75mg, end stage renal disease (ESDR) on hemodialysis, and confirmed AAV on prednisone presented

to the emergency department with one minute of non-radiating midsternal chest tightness during dialysis treatment. Initially, his HR was 168, BP 66/26, RR 20, SpO2 98%, and Temp 97.4F. Electrocardiogram (EKG) was originally interpreted as AF with Rapid Ventricular Response (AFRVR). Patient was given loading dose of amiodarone 150mg with continued amiodarone gtt and admitted for observation. Three-hour serial Troponin levels were 0.05ng/ mL, 0.8ng/mL, and 0.15ng/mL. Twenty-four hour troponin was 0.17ng/mL and CPK was within normal limits. The patient’s vital signs stabilized to HR 80, RR 20, BP 133/66, SpO2 98%, and Temp 97.4F after amiodarone treatment. Cardiology consult interpreted the EKG as Supraventricular Tachycardia (STV) and amiodarone was discontinued. Transesophageal echocardiogram showed left ventricular ejection fraction of 60%. Patient remained stable and discharged with increased carvedilol to 25mg BID and continued clopidogrel 75mg with a Cardiology follow up. Conclusions: Cardiac disease is often reported within one year of AAV diagnosis. However, it is believed cardiac involvement silently begins much earlier. Our patient had a history of HTN, HLD, CAD, and ESDR prior to SVT presentation; though, per chart review, all diagnoses began

within 6 months of AAV diagnosis. Our patient began ESDR which led the nephrologist to pursue a larger differential diagnosis, eventually confirming AAV. Although vascular, cardiac, and renal dysfunctions were being treated before confirmatory AAV diagnosis, one cannot truly say which came first. It is more believable to proceed with AAV causing the following disorders in a previously healthy individual than to assume all to be independent in nature. Our patient did have a history of multiple EKGs suggesting sinus rhythm with premature supraventricular complexes and aberrant ventricular response, a specific type of Atrial Flutter, prior to AAV diagnosis. A direct link between Atrial Flutter and SVT has been shown on multiple occasion due to the close pathophysiology, whereas AF has shown no correlation with SVT. With this association, it is likely our patient had a history of Atrial Flutter from AAV which ultimately presented as an SVT rather than the common AF, still suggesting a rare AAV presentation of Atrial Flutter or SVT. Our patient’s EKG history later proved to demonstrate persistent sinus rhythm with premature supraventricular complexes and aberrant ventricular response ultimately leading to left atrial appendage closure procedure with Watchman FLX Device.

69 2024 Via Research Recognition Day