Rituximab Induced Left Bundle Branch Block

Increasing evidence indicates that patients with chronic inflammatory arthritis (CIA), including rheumatoid arthritis and spondyloarthropathies, have an increased risk of arrhythmic events, significantly contributing to the higher cardiovascular disease (CVD) morbidity and mortality observed in these subjects compared to the general population. Although the mechanisms accounting for such an arrhythmogenic substrate are not fully understood, the main role is probably played by chronic systemic inflammation, able to accelerate the development of structural CVD, as well as to directly affect cardiac electrophysiology. In the past decade, biologic therapies have revolutionized the treatment of CIA by highly enhancing the probability to effectively control disease activity and its systemic consequences, including cardiovascular involvement. Accordingly, accumulating data demonstrated that by potently inhibiting systemic inflammation, biologic drugs can reduce CVD progression and ameliorate arrhythmic risk parameters, with a putative beneficial impact on arrhythmia incidence. Nevertheless, a significant number of reports from clinical trials and postmarketing experience suggest that some of these medications, particularly TNF inhibitor monoclonal antibodies and rituximab, may in some circumstances precipitate arrhythmia occurrence, probably by acutely amplifying myocardial electric instability intrinsically associated with these diseases. In this review, we analyze the intricate link between biologic drugs and arrhythmias in CIA in the effort to identify which factors are involved in the fine-tuning of antiarrhythmic/pro-arrhythmic balance, and understand how this knowledge should be translated in the clinical practice to obtain the most favorable benefit-to-risk profile when biologic drugs are used in these patients.

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Biologic drugs and arrhythmic risk in chronic inflammatory arthritis: the good and the bad

Lazzerini

Capecchi

Gargiulo

et al. 2016

Immunol Res

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Bicarbonate refractory QRS prolongation and left bundle‐branch block following escitalopram and lamotrigine overdose: A case report and literature review of toxic left bundle‐branch block

et al. 2018

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Outcomes of cardiac resynchronization therapy in patients with chemotherapy‐induced cardiomyopathy

Ezzeddine

Saliba

Jain

et al. 2021

Pacing Clinical Electrophis

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Background Several chemotherapy agents are associated with the development of non‐ischemic cardiomyopathy (NIC). When chemotherapy‐induced cardiomyopathy (CHIC) is associated with left bundle branch block (LBBB) and a left ventricular ejection fraction (LVEF) 35% or lower, cardiac resynchronization therapy (CRT) is often utilized to improve cardiac function and relieve symptoms. Objective To determine the echocardiographic and clinical outcomes of CRT in patients with CHIC. Methods The study included 29 patients with CHIC (CHIC group) and 58 patients with other types of NIC (control group) who underwent CRT implantation between 2004 and 2017. The primary endpoints were changes in LVEF, left ventricular end‐systolic diameter (LVESD), and left ventricular end‐diastolic diameter (LVEDD) at 6–18 months after CRT. The secondary outcomes included changes in left ventricular global longitudinal strain (GLS), systolic strain rate (SRS), early diastolic strain rate (SRE), and overall survival. Results Out of 29 patients with CHIC, 62.1% received chemotherapy for lymphoma, 13.7% for breast cancer, and 24.1% for sarcoma. The agent implicated in 93.1% of the patients was an anthracycline. Half of the patients had LBBB. The mean baseline LVEF was 28% ± 8%. The mean baseline QRS duration was 146 ± 26 ms. Twenty‐eight patients had post‐CRT follow‐up data. CRT was associated with improvement in echocardiographic outcomes in the CHIC group and the control group. There was no difference in overall survival between the two groups (log‐rank p = .148). Conclusion CRT improves left ventricular function and reverses remodeling in patients with CHIC.

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Rituximab Induced Left Bundle Branch Block

Abstract: Rituximab (a monoclonal antibody directed against CD 20) therapy can be acutely complicated by infusion reactions and cardiac arrhythmia on rare occasions. We report the first case of a new onset left bundle branch block (LBBB) after rituximab therapy for Wegener's vasculitis.

Cited by 3 publications

References 11 publications

Biologic drugs and arrhythmic risk in chronic inflammatory arthritis: the good and the bad

Biologic drugs and arrhythmic risk in chronic inflammatory arthritis: the good and the bad

Bicarbonate refractory QRS prolongation and left bundle‐branch block following escitalopram and lamotrigine overdose: A case report and literature review of toxic left bundle‐branch block

Outcomes of cardiac resynchronization therapy in patients with chemotherapy‐induced cardiomyopathy

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