Cholestatic Bradycardia: The Story of Rising Bilirubin and a Slowing Heart: A Case Report of a 74 Years Old Female Patient at the University of Nigeria Teaching Hospital in Enugu, Nigeria

The association between Cholestatic jaundice and bradycardia has been well documented with reports of a variety of bradyarrhythmias. Although its actual mechanism of development has remained elusive to clinicians, bradycardia/ bradyarrhythmia has however been known to complicate the course and outcome of obstructive jaundice. Here we report the case of a 74-year-old woman with obstructive jaundice secondary to carcinoma of the head of the pancreas. As her serum bilirubin and bile acids continued to rise she developed progressive bradycardia and other dysrhythmias, manifesting with syncope and was referred to us, cardiologists, for correction. By vagal antagonism, enhancement of bile acid elimination, and surgical biliary diversion under temporary pacemaker support, the rhythm disorders were reversed.

Methods: Serial serum bilirubin and bile acids assay and electrocardiogram (ECG) were done every three days. The total/direct bilirubin rose progressively from 28.4/17.6 umol/L at the outset to 501.5/234.0 umol/L. The bile acids equally increased steadily from Aspartate Transaminases/ Alanine Transaminases/ Alkaline Phosphatase (AST/ALT/ALP) levels = 96/81/1037 IU/L to as high as AST/ALT/ALP = 580/400/7000 IU/L. Patient manifested cardiac rhythm disorders including sinus bradycardia with first-degree atrioventricular (AV) block and heart rate (HR) of 54/min, Mobitz type 2 AV block (HR =40/min), and Complete heart block (HR=33/min) over two weeks period.

Results: Following the commencement of bile acid eliminants, vagal stimulation antagonists, and surgical biliary diversion under temporary pacemaker support, reversal of the bradyarrhythmias was achieved and HR normalized within 3 3-week periods.

Conclusion: This case demonstrated that cholestatic bradycardia is reversible if well-managed.