Moffitt AM Report 4/25/17: Complete Heart Block and Cardiac Sarcoid


Good morning everyone!

Thank you Carine and Tim for presenting the case of a middle aged man with a history of complete heart block (of unclear etiology) status post PM placement, who presented with evidence of L and R sided thromboembolism (PE and LV thrombus) as well as new cardiomyopathy, who was ultimately diagnosed with cardiac sarcoidosis!





  • New onset heart block in a young person cannot be assumed to be native conduction disease. We must rule out secondary causes (toxic/metabolic, infiltrative, or ischemic processes).
  • Malignancy is the most common cause of a hemorrhagic, pericardial effusion
  • Cardiac sarcoidosis is rare, and has been described in 5% of patients with systemic sarcoid, but autopsy studies indicate that subclinical cardiac involvement is present in up to 70% of cases


Complete Heart Block in a Young Patient

  • In >50% of cases, no specific, reversible causes are identified. However, when a young patient presents with CHB, the diagnosis idiopathic progressive conduction disease should NOT be assumed (always search for secondary, reversible causes).
  • Congenital Causes of Complete Heart Block
    • Autoimmune congenital CHB: usually due to transplacental passage of maternal autoantibodies to Ro/SSA and/or La/SSB that damage developing conduction tissue
    • Structural heart abnormalities due to congenital heart disease (eg congenitally corrected transposition of great arteries, endocardial cushion defects)
    • Idiopathic familial congenital CHB
  • Acquired Causes of Complete Heart Block
    • Iatrogenic: meds, post-cardiac surgery, post-catheter ablation, post-TAVR
    • Pathologic : Ischemia : Infiltrative – sarcoidosis, amyloidosis, malignancies : Myocarditis (eg Lyme Disease) : Endocarditis with abscess formation : Electrolyte abnormalities : Endocrinopathy

Cardiac Sarcoidosis (Blast from the past of VA & Moffitt Pearls!)

  • Clinical evidence of myocardial involvement have been described in 5% of patients with systemic sarcoid, but autopsy studies indicate that subclinical cardiac involvement is present in up to 70% of cases!
  • Clinical Manifestations depend on location and extent of granulomatous inflammation.
    • AV block or bundle-branch block: most common finding in patients with clinically evident cardiac sarcoid
    • Tachyarrhythmias
    • Cardiomyopathy
    • CHF
    • Sudden cardiac death
    • Pericardial disease
  • When to suspect cardiac sarcoidosis?
    • Young adults (< 55 yoa) with unexplained 2nd or 3rd degree AV block
    • Young adults (< 55 yoa) with new ECG abnormalities or symptoms in the absence of coronary artery disease or inherited CV disease
    • Patients with sustained monomorphic VT
    • Patients with clinical diagnosis of extracardiac sarcoidosis
  • Diagnosis: Challenging and frequently missed/delayed
    • There are various guidelines proposed by various different societies! Usually based on a combination of ECG, echo, MRI/PET, and endomyocardial biopsy
    • ECHO: 1st line imaging. LV dilatation, septal thinning, segmental or global hypokinesia of the LV or RV, aneurism formation, valvular regurgitation, simulated LV hypertrophy from infiltration into the myocardium.
    • Cardiac MRI: Technique of choice for the dx of cardiac sarcoid w/ the highest sensitivity and specificity. Late gadolinium enhancement (LGE) may have prognostic value in evaluating chronic sarcoid as you have scar formation and increased risk of death presumably from arrhythmia.
    • Cardiac PET: Excellent imaging modality for active sarcoid, but less specific as can have false positives with other inflammatory myocardial diseases.


Evernote Link:



Filed under: Morning Report

How To Stop Nausea Without Medications

Management of a vomiting patient is typically an unpleasant experience for any provider.  Even if the sight, smell, or sound produced by someone vomiting does not bother you, there is often a particularly foul clean-up process that must occur after treatment has concluded.  However, there is a little-known trick that you can use to stop nausea quickly, …

The post How To Stop Nausea Without Medications appeared first on Ditch Doc EM.

Smoking cessation: Is abrupt quitting more effective than a gradual approach?

Lindson-Hawley N, Banting M, West R, Michie S, Shinkins B, Aveyard P. Gradual versus abrupt smoking cessation. A randomized, controlled noninferiority trial. Ann Intern Med 2016;164(9):585-592. Patients in the “abrupt cessation group” were asked to stop smoking on their quit day. Participants in the “gradual cessation group” were also given short-acting nicotine products (gum, lozenges, … Continue reading "Smoking cessation: Is abrupt quitting more effective than a gradual approach?"

Lung ultrasound for paediatric pneumonia

Q. Can Lung ultrasound reduce need for CXR in children with suspected pneumonia? Jones BP, Tay ET, Elikashvili I, et al. Feasibility and safety of substituting lung ultrasonography for chest radiography when diagnosing pneumonia in children: a randomized controlled trial. Chest 2016;150(1):131-138. randomized 191 children and adolescents with clinically suspected pneumonia to receive either CXR always … Continue reading "Lung ultrasound for paediatric pneumonia"

What is the best duration for nicotine replacement therapy?

  —525 smokers enrolled. —Randomized groups for nicotine replacement via patch at 8, 24, 52 weeks —6 month cessation rates were significantly higher if patches used for 24 wks. vs 8 wks. —No adverse effects noted —Cost effective benefit long term. —No additional therapeutic advantage with long term treatment (up to 52 weeks) —Worsened adherence … Continue reading "What is the best duration for nicotine replacement therapy?"