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Case Rep the 1 last update 12 Jul 2020 Oncol MedCase Rep Oncol Med. 2017; 2017: 7304021.
Heartburn Remedies Treatment (⭐️ Simples Steps To) | Heartburn Remedies List Ofhow to Heartburn Remedies for Published online 2017 Dec 10. doi: 10.1155/2017/7304021
PMCID: PMC5742500
PMID: 29375920

Heartburn Remedies 6 Ways To Get Relief During (β˜‘ 9 Home Remedies) | Heartburn Remedies 10 Foods To Eathow to Heartburn Remedies for Kanupriya Mathur

1Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA

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Aditya Saini

2Department of Cardiac Electrophysiology, Virginia the 1 last update 12 Jul 2020 Commonwealth University, Richmond, VA, USA 2Department of Cardiac Electrophysiology, Virginia Commonwealth University, Richmond, VA, USA

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Kenneth A. Ellenbogen

2Department of Cardiac Electrophysiology, Virginia Commonwealth University, Richmond, VA, USA

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Richard K. Shepard

2Department of Cardiac Electrophysiology, Virginia Commonwealth University, Richmond, VA, USA

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1Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
2Department of Cardiac Electrophysiology, Virginia Commonwealth University, Richmond, VA, USA
Corresponding author.
Kanupriya Mathur: [email protected]
Academic Editor: Josep M. Ribera
Received 2017 Aug 9; Accepted 2017 Nov 13.
Copyright © 2017 Kanupriya Mathur et al.
This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

Ibrutinib is a Bruton''s tyrosine kinase (BTK) inhibitor approved for use in patients with mantle cell lymphoma (MCL), chronic lymphocytic leukemia (CLL), and Waldenström macroglobulinemia. Ibrutinib use has been linked to increased incidence of atrial fibrillation and hypertension in multiple studies [14]. Other forms of cardiac toxicities have also been reported in isolated case reports [5]. We report a case of recurrent and profound sinus arrest in a patient treated with ibrutinib for MCL.

2. Case Report

Heartburn Remedies Which Foods To Avoid (⭐️ To Avoid) | Heartburn Remedies Diet Changes Forhow to Heartburn Remedies for A 76-year-old Caucasian female with a past medical history of mantle cell lymphoma (MCL), hypertension, and gastroesophageal reflux disease presented to the hospital with intractable nausea and vomiting of one week duration. With regard to treatment of her MCL, she had failed first-line treatment with bendamustine-rituximab following which she had received R-CHOP (rituximab, cyclophosphamide, vincristine, and prednisolone) chemotherapy. However, due to her advancing disease detected by positron emission tomography imaging and lymph node biopsy, she was started on ibrutinib 560 mg daily 11 days ago. She took the medication for 8 days after which she could not tolerate it due to intractable nausea and vomiting. She was unable to tolerate any of her other medications and quit taking all of them 5 days prior to admission. Her other home medications were reviewed, which included atorvastatin 20 mg daily, carvedilol 3.125 mg twice daily, citalopram 10 mg daily, and lisinopril 5 mg daily. While in the hospital, she continued to have nausea for two more days. During this time, her potassium (K+) level was low (range: 2.4–3.2 meq/L), and she received K+ replacement. In the first 48 hours of hospitalization, she experienced 2 episodes of brief syncope lasting a few seconds and sinus pauses (up to 6 seconds), which appeared to be vagally mediated, as they occurred immediately after an episode of retching or coughing. Her baseline 12-lead electrocardiogram showed normal sinus rhythm with normal PR interval and preexisting right bundle branch block with QRS duration of 138 milliseconds. She had no prior history of syncope, bradycardia, or any cardiac illness. She had no family history of sudden cardiac death. At the time of the event, she was not on any medications known to have a potential to cause bradycardia. Transthoracic echocardiogram revealed an ejection fraction of 60–65% and was otherwise normal.

By the third day of hospitalization, her symptoms had resolved and she was able to tolerate solid food with no difficulty. Her electrolytes were in normal range. However, she suddenly had a witnessed syncopal episode correlating with 26 seconds of sinoatrial arrest noted on telemetry (Figure 1). The episode was abrupt in onset. The patient was in bed and was talking to her nurse when she had this syncopal episode. She regained her baseline level of consciousness after the episode with no residual deficits. Cardiology consult was obtained, and a permanent pacemaker was planned. While awaiting pacemaker implantation, she developed two more symptomatic episodes of abrupt onset sinus pauses over next 24 hours without any trigger. A dual-chamber permanent pacemaker was implanted the next day. Patient was not given ibrutinib again.

Telemetry recording from the time of syncopal event in our patient demonstrating sinoatrial arrest and a 26-second pause. Notice the absence of any atrial activity during the pause indicating this is sinus pause rather than AV block. The telemetry marks some tremor artifact during the event erroneously as atrial activity (A) which is another important finding to recognize.

3. Discussion

Ibrutinib is a Bruton''s cardiac toxicity, as referred by Tang et al. in 2017 [9]. One case of new onset cardiomyopathy and ventricular tachycardia has been reported with ibrutinib use [8]. The exact spectrum of cardiac manifestations of the the 1 last update 12 Jul 2020 medication as well as relation to dose and duration of therapy remains to be studied.Ibrutinib is a Bruton''s cardiac toxicity, as referred by Tang et al. in 2017 [9]. One case of new onset cardiomyopathy and ventricular tachycardia has been reported with ibrutinib use [8]. The exact spectrum of cardiac manifestations of the medication as well as relation to dose and duration of therapy remains to be studied.

A detailed cardiovascular safety report, published in the Drug Safety journal in 2015, describes the common cardiac effects associated with tyrosine kinase inhibitors (25 medications) approved for several oncologic indications. These include hypertension, pulmonary hypertension, bleeding, arterial and venous thrombosis, congestive heart failure, QT prolongation and associated arrhythmias, sudden death, and syncope. To our knowledge, this is the first case report of recurrent profound bradycardia due to paroxysmal sinoatrial arrest in a patient treated with ibrutinib. The authors would like to emphasize that it is possible our patient had previously undiagnosed sick sinus syndrome or autonomic dysfunction, which may have been the cause of sinus pauses and syncope. However, in light of recent use of ibrutinib in our patient, a medication that has been linked to cardiac side effects as well as with absence of any history of prior syncopal or presyncopal symptoms, the hypothesis that ibrutinib use resulted in profound depression of the sinus node or aggravated preexisting subclinical sinus node dysfunction has to be entertained.

4. Conclusion

Heartburn Remedies Acid Reflux (πŸ‘ 11 Foods That Help) | Heartburn Remedies Natural Remedieshow to Heartburn Remedies for With ever-expanding indications for chemotherapeutic agents and immunomodulators, the clinician must remain vigilant for unknown and rare systemic manifestations that may be associated with their use. Some of these effects may be potentially life-threatening. Our case highlights the need for further studies aimed at providing mechanistic insights into cardiac toxicities of ibrutinib.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

References

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