Cardiac Arrhythmias and Defects in Systemic Sclerosis
Cardiac Arrhythmias and Defects in Systemic Sclerosis
The cardiac workup in patients with SSc includes routine and second-level investigations, both for electrical assessment and heart evaluation, as summarized in Table 1. Standard 12-lead ECG as well as Doppler echocardiography should be performed routinely in all SSc patients, even if the patient is asymptomatic. If the patient complains of palpitations, syncope or dizziness, the next steps must include exercise testing, upright tilt-table testing and 24-h Holter monitoring.
When significant changes are detected in the conduction and rhythm systems, careful investigations for heart disease must be performed. First, classic cardiovascular risk factors should be assessed together with any potential signs or symptoms of ischaemic heart disease. If SHD is suspected, echocardiography should be performed, when possible, by pulsed Doppler. In addition, cardiac MRI to evaluate tissue damage may be considered, particularly if there are any signs of myositis, in order to rule out myocarditis, which demands specific management.
Although not yet endorsed by any guideline, given the high prevalence and the prognostic significance of arrhythmias and conduction defects, we believe that 24-h Holter monitoring should be considered as part of routine evaluation in SSc patients, even if asymptomatic, every 1–2 years. A validation study to determine the possible impact of such an attitude and the ideal time interval is warranted. The patient should also be questioned about the presence of systemic illnesses that can be associated with arrhythmias such as chronic obstructive pulmonary disease, hyperthyroidism, pericarditis and congestive heart failure. Moreover, in SSc, several complications might favour arrhythmia, such as life-threatening infections related to severe motility disorders of the intestine or electrolyte imbalance because of gut or kidney involvement. Measurement of HRT and HRV should be considered in selected patients after detailed clinical, echocardiographic and standard ECG and Holter monitoring evaluations. Invasive electrophysiological studies are indicated in patients who have atrioventricular block, intraventricular conduction disturbance, sinus node dysfunction, tachycardia and unexplained syncope or palpitations.
Diagnostic Workup
The cardiac workup in patients with SSc includes routine and second-level investigations, both for electrical assessment and heart evaluation, as summarized in Table 1. Standard 12-lead ECG as well as Doppler echocardiography should be performed routinely in all SSc patients, even if the patient is asymptomatic. If the patient complains of palpitations, syncope or dizziness, the next steps must include exercise testing, upright tilt-table testing and 24-h Holter monitoring.
When significant changes are detected in the conduction and rhythm systems, careful investigations for heart disease must be performed. First, classic cardiovascular risk factors should be assessed together with any potential signs or symptoms of ischaemic heart disease. If SHD is suspected, echocardiography should be performed, when possible, by pulsed Doppler. In addition, cardiac MRI to evaluate tissue damage may be considered, particularly if there are any signs of myositis, in order to rule out myocarditis, which demands specific management.
Although not yet endorsed by any guideline, given the high prevalence and the prognostic significance of arrhythmias and conduction defects, we believe that 24-h Holter monitoring should be considered as part of routine evaluation in SSc patients, even if asymptomatic, every 1–2 years. A validation study to determine the possible impact of such an attitude and the ideal time interval is warranted. The patient should also be questioned about the presence of systemic illnesses that can be associated with arrhythmias such as chronic obstructive pulmonary disease, hyperthyroidism, pericarditis and congestive heart failure. Moreover, in SSc, several complications might favour arrhythmia, such as life-threatening infections related to severe motility disorders of the intestine or electrolyte imbalance because of gut or kidney involvement. Measurement of HRT and HRV should be considered in selected patients after detailed clinical, echocardiographic and standard ECG and Holter monitoring evaluations. Invasive electrophysiological studies are indicated in patients who have atrioventricular block, intraventricular conduction disturbance, sinus node dysfunction, tachycardia and unexplained syncope or palpitations.
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