(P051) CARDIAC MANIFESTATIONS OF MESALAMINE USE IN INFLAMMATORY BOWEL DISEASE: CASE REPORT AND REVIEW OF THE LITERATURE

Introduction:

Inflammatory bowel disease (IBD), including Crohn’s disease and ulcerative colitis, is classically associated with gastrointestinal symptoms, but is associated with a wide variety of extra-intestinal manifestations as well. Cardiovascular manifestations include myocarditis, pericarditis, and arrhythmias. Cardiac symptoms in IBD can occur as an extra-intestinal manifestation of the disease process or as an adverse event related to the treatment regimen of IBD.

Case Presentation:

The patient is a 44-year-old female with Crohn’s disease presenting to the emergency department for abdominal pain and hematochezia. The patient reports several episodes of Crohn’s disease flare-ups over the past six years which have increased in frequency. The patient was not currently on a medication regimen for her Crohn’s disease as she was unable to afford the azathioprine which she was previously prescribed. A CT of the abdomen was ordered and showed no acute changes. The patient was started on IV methylprednisolone and mesalamine 4.8 grams daily for her Crohn’s disease flare-up. On initial presentation, patient presented with a heart rate of 69. Within 24 hours of admission and following the administration of mesalamine, patient presented with lightheadedness and dizziness. Over the next few days, patient had worsening symptomatic bradycardia decreasing to 32 beats per minute. An EKG showed sinus bradycardia with no evidence of heart block. The transthoracic echocardiogram showed ejection fraction of 55-60% and was otherwise unremarkable. Over the next five days, the patient’s heart rate improved to the 60s as her Crohn’s flare-up improved and the mesalamine dosage was reduced.

Discussion:

While cardiovascular manifestations of IBD are rare, they have a higher prevalence than in the general population. Cardiovascular manifestations reported in the literature include myocarditis, pericarditis, arrhythmias, heart block, myocardial infarction, and heart failure. Diagnosis of the etiology of these cardiac manifestations may be difficult as treatments of IBD can also have cardiotoxic effects. One example is mesalamine which in rare cases has been reported as a cause for symptomatic bradycardia. Of the published cases, bradycardia generally occurred among younger females between age 21-45, with bradycardia typically presenting within a short period of time following initiation of mesalamine treatment. Other cardiac manifestations reported to be associated with mesalamine use include myocarditis, pericarditis, and heart failure. 

Conclusion:

Mesalamine-induced symptomatic bradycardia in IBD has only been published on rare occasions in the literature. Mesalamine can result in a variety of cardiovascular complications and as a result, regular monitoring for cardiovascular manifestations following mesalamine administration is recommended.