Background Ventricular ectopic beats (VEBs) are associated with a substantial increase in the risk of sudden and total cardiac death, both in the general population and in Systemic Sclerosis (SSc) patients (1,2). Beta-blockers are the mainstay of medical suppression of VEBs but are not routinely used in SSc patients due to possible Raynaud's phenomenon exacerbation and digital ischemic complications.
Objectives To evaluate safety and effectiveness of beta-blockers in SSc patients with heart involvement and arrhythmic burden.
Methods 96 patients of our cohort with signs and/or symptoms suggestive of cardiac involvement (dyspnoea, palpitations and/or rise of cardiac enzymes) underwent 24h-ECG-Holter. Among these, 14 patients with palpitations and/or frequent VEBs were treated with beta-blockers and prospectively followed. Ten patients were treated with bisoprolol (doses between 1.25-5 mg/day) and 4 with carvedilol. A complete assessment of disease characteristics and cardiac involvement was also performed and, after a mean follow-up of 14.0±9.4 months, a second 24h-ECG-Holter was performed. The effects on active ulcers were examined.
Results Eighteen patients (18.9%) presented VEBs >1000/24h at baseline. Considering the 14 patients treated with beta-blockers (mean age:47.5 years; mean disease duration:6.4 years; diffuse disease:57.1%; anti-Scl70 positivity: 64.3%), all of them presented an increase of troponin T and 8 (57.1%) a right bundle branch block. An history of digital ulcers was present in the majority of patients (71.4%) and 7 of them (50%) presented active ulcers at the time of study enrolment, 3 of whom with tissue loss. All patients were on sinus rhythm and none of them presented ST/T alterations; the mean number of VEBs at baseline was strikingly higher (6917.4±9911.9/24h) and 9 patients (64.3%) had a number of VEBs>1000/24h, that were polymorphic in 6 (42.8%). In 6 patients (42.8%), moreover, an episode of non-sustained ventricular tachycardia (NS-VT), the longest of 34 beats, was recorded. After beta-blockers treatment, the number of VEBs decreased in 10 patients (71.4%). The relative mean reduction was 74.7% (range:41.7-100%), while the absolute mean reduction was 4753.4±5610 VEBs/24h, with a range of 183-14408 VEBs/24h. The number of VEBs remained stable in the only 3 patients who presented a baseline number of VEBs<30/24h, and it increased in one patient. Considering the 9 patients with VEBs>1000/24h at baseline, in 3 (33.3%) the treatment with bisoprol led the number of VEBs far below this prognostic cut-off value, while among the 6 patients with baseline NS-VT, 3 had no more episodes recorded at follow-up. Despite continuative beta-blocker therapy, none of the patients presented a worsening of digital and legs ulcers, that rather improved in 4 patients, and none developed new digital ulcers. The Raynaud's phenomenon remained stable in all patients.
Conclusions Despite the small number of patients in this pilot study, our data suggest the efficacy of beta-blockers in reducing VEBs without an increase of digital ulcers complication or worsensing of Raynaud's phenomenon.
Kostis JB. Am J Med 1988;84:1007-14.
Ataklte F. Am J Cardiol 2013;112:1263-70.
Disclosure of Interest None declared