9.23 SFGH pearls: pHTN, levamisole and cardioversion!

  • The classic CXR of a patient with pulmonary hypertension shows enlarged pulmonary arteries with diminished peripheral vessels (“oligemic” lung fields)
    • A pulmonary trunk larger than the ascending aorta on CT is radiographic sign of PH, as is any enlargement of the pulmonary arteries
  • Pericardial effusion in pulmonary hypertension is known to confer a poor prognosis. Being over 45, low RV EF and SVT, a this patient had, are also poor prognostic signs
  • Levamisole vasculitis is associated with positive ANCAs (p-ANCA or both P- and C-ANCA), anti-phospholipid antibodies and leukopenia or neutropenia.
    • Patients classically present with painful purpura on the ears and retiform purpura on the trunk or extremities
    • A lab test for levamisole in urine is available but usually of low yield because levamisole has a short half life
  • Amiodarone causes cardioversion to sinus rhythm in up to 40% of patients (!)
    • This area is controversial, but one small study (Escudero, below) showed that patients not on anticoagulation who cardioverted from AF on amio had normal atrial function within 24 hours and no thrombus formation 7 days later, suggesting anticoagulation may not be needed after cardioversion
  • General recommendations are to anticoagulate for 4 weeks before and after elective cardioversion (prior not necessary if TEE can rule out existing clot)

o   Post-cardioversion anticoag is because of delayed atrial function after cardioversion and because many patients will have asymptomatic recurrent episodes of their arrhythmia

Evernote link here: https://www.evernote.com/shard/s300/sh/d573484e-e949-43f0-8604-97f7dc794f20/8c4cb6d3f7a0003e496bebe771e3a43c

Chung C, Tumeh PC, Birnbaum R, et al. Characteristic purpura of the ears, vasculitis, and neutropenia–a potential public health epidemic associated with levamisole-adulterated cocaine. J Am Acad Dermatol 2011; 65:722.

Page RL, Wilkinson WE, Clair WK, et al. Asymptomatic arrhythmias in patients with symptomatic paroxysmal atrial fibrillation and paroxysmal supraventricular tachycardia. Circulation 1994; 89:224.

Fenstad ER, Le RJ, Sinak LJ, et al. Pericardial effusions in pulmonary arterial hypertension: characteristics, prognosis, and role of drainage. Chest 2013; 144:1530.

Escudero EM, San Mauro M, Laugle C. Bilateral Atrial Function After Chemical Cardioversion of Atrial Fibrillation with Amiodarone: An Echo Doppler Study. J Am Soc Echocardiogr. 1998. Apr;11(4):365-71.

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