Lyme Carditis: A Rare Presentation of Sinus Bradycardia Without Any Conduction Defects.

Lyme carditis is a rare cardiac manifestation of Lyme disease that occurs when bacterial spirochetes infect the pericardium or myocardium triggering an inflammatory response. The most common electrocardiogram (EKG) findings in these patients include atrioventricular (AV) conduction abnormalities (first, second, and third degree heart block). A 56-year-old male with a history of hypothyroidism, from the Northeastern region of the United States, presented to the emergency department with lightheadedness and chest pain. His EKG revealed sinus bradycardia with a heart rate of 49 beats per minute, without ST segment elevation, T wave inversions, or signs of heart block. An enzyme-linked immunosorbent assay (ELISA) Lyme titer was elevated, and confirmatory Western blot was positive for IgG and negative for IgM. He was treated with intravenous (IV) ceftriaxone; however, he continued to have persistent bradycardia with his heart rate dropping to 20 to 30 beats per minute throughout the night. Additionally, he had several sinus pauses while sleeping, with the longest lasting for 6.1 seconds. A pacemaker and an additional three-week course of IV ceftriaxone was determined to be the best treatment for his resistant bradycardia secondary to Lyme carditis. No symptoms were present at his one month follow-up appointment, as an outpatient, after completing ceftriaxone therapy. The patient follows up with cardiology regularly to have his pacemaker checked. Here we present a unique case of Lyme carditis, without the classical findings of Lyme disease or common EKG findings of AV conduction abnormalities. A high clinical suspicion of Lyme carditis is required when someone from a Lyme endemic region presents with unexplained cardiac symptoms and electrocardiogram abnormalities. This case report aims to add to the knowledge gap between suspicion of Lyme carditis and sinus bradycardia as the only presenting symptom.

Enhanced external counterpulsation is an effective treatment for Syndrome X.

Enhanced external counterpulsation (EECP) was used to treat 30 patients with refractory angina due to cardiac Syndrome X, with an initial improvement in CCS angina class (3.57 to 1.43; p<0.001) and regional ischemia in all treated patients. At a mean of 11.9 months follow-up, 87% of patients had sustained improvement in angina and were without MACE. EECP, by improving endothelial function, may be an effective and durable treatment for this often difficult to treat problem.