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Challenges in Clinical Electrocardiography |

Reversible High-Grade Atrioventricular Block Associated With Cocaine Use

Philip S. Hall, MD1; Babak Nazer, MD1; Randall J. Lee, MD, PhD1
[+] Author Affiliations
1Division of Cardiology, University of California, San Francisco
JAMA Intern Med. 2015;175(12):1965-1967. doi:10.1001/jamainternmed.2015.5372.
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A woman in her 50s with a history of intravenous drug use and hepatitis C was admitted with a diagnosis of community-acquired pneumonia. Physical examination demonstrated violaceous plaques on her ears, fingertips, hands, elbows, and ankles. She reported recent injection use of cocaine, 2 days prior to admission. Urine toxicologic analysis detected cocaine, opiates, and amphetamines, and extended testing results were positive for levamisole. Antinuclear antibodies were present at a titer of 1:40, and both antineutrophil cytoplasmic antibodies (ANCAs) (antiproteinase 3 at 63.5 chemiluminescence [CU] units [reference, <20 CU]) and antimyeloperoxidase antibodies (31.1 CU [reference, <20 CU]) were present. Punch biopsy of an arm lesion demonstrated a leukocytoclastic vasculitis with small-vessel thrombosis, consistent with levamisole-associated vasculitis. On her second hospital day, she was noted to have an irregular heart rhythm on telemetry, and 12-lead telemetry electrocardiograms (ECGs) were reviewed (Figure 1 and Figure 2).

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Figure 1.
Electrocardiogram From the Onset of the Episode

Telemetry demonstrates sinus rhythm with QS complexes in V1 and V2 and abrupt onset of 2:1 AV block.

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Figure 2.
Electrocardiogram (ECG) Taken as the Episode Progressed

The ECG demonstrates a regular P-wave rate (asterisks) at approximately 85 beats per minute. In addition, 4 QRS complexes are present, the first, second, and fourth of which are morphologically identical to the baseline QRS and likely represent intact AV nodal conduction. However, the second QRS complex has a slightly shorter PR interval (β) than the first and fourth complexes (α) and may represent either AV conduction with slight change in atrioventricular (AV) delay or a junctional escape beat. This portion of the ECG is suggestive of high-grade AV block, defined as intermittent AV conduction with a P:QRS ratio of at least 3:1. The third QRS complex is wide and represents a ventricular escape beat (arrowhead), suggesting a period of transient complete heart block (bracket).

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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