Oral theophylline for treatment of painful left bundle branch block

Q: What are the key findings of this study?

Oral theophylline 100 mg twice daily resulted in complete resolution of chest pain during routine activities at 1-month and 3-month follow-ups in a 71-year-old man with painful LBBB.

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Painful left bundle branch block (LBBB) (n=1). Intervention: Oral theophylline. Primary outcome: Resolution of chest pain during routine activities.

Q: What does this research mean for the field?

Oral theophylline provides effective symptomatic relief for painful left bundle branch block when standard sinus node suppression and pacing therapies fail or are unsuitable. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.ESTABLISHES_NEW_DIRECTION.

Rawan Amir; Rachit M. Vakil; William G. Stevenson; Harikrishna Tandri

doi:10.1016/j.hrcr.2023.02.017

May 18, 2023HeartRhythm Case ReportsOpen Access

Oral theophylline for treatment of painful left bundle branch block

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Key result

Oral theophylline completely resolves chest pain in a patient with painful LBBB.

n=1

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Why the study?

The pathophysiology of painful left bundle branch block is not yet understood, and alternative medical management strategies are needed when standard approaches fail or invasive pacing is not desired.

Does oral theophylline resolve chest pain in a patient with painful left bundle branch block refractory to beta-blockers and ranolazine?

Key Points

To describe the clinical presentation, electrophysiologic evaluation, and novel medical management of painful left bundle branch block with oral theophylline.
Evaluated a patient presenting with exercise-induced chest pain linked to intermittent left bundle branch block (LBBB) after excluding coronary artery disease and myocardial ischemia.
Conducted an electrophysiology study (EPS) assessing conduction dynamics with isoproterenol, followed by outpatient initiation of oral theophylline at 100 mg twice daily (200 mg/day total).
Administration of isoproterenol during EPS restored conduction and allowed atrial pacing up to 127 bpm without precipitating LBBB or chest pain.
Treatment with oral theophylline at 200 mg/day in divided doses resolved painful LBBB symptoms without requiring further titration and with no adverse side effects during follow-up.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

Does oral theophylline resolve chest pain in a patient with painful left bundle branch block refractory to beta-blockers and ranolazine?

P

Population

1 male patient (age 71) with painful rate-related left bundle branch block without underlying ischemia, refractory to ranolazine and propranolol, followed for 3 months.

I

Intervention

Oral theophylline 100 mg twice daily (total 200 mg/day) for 3 months (preceded by diagnostic isoproterenol infusion up to 20 mcg/kg/min during electrophysiology study).

O

Outcome

Symptom relief (resolution of chest pain during routine activities) at 1-month and 3-month follow-ups.patient reported

This case report presents the first documented successful management of painful left bundle branch block using oral theophylline to augment AV nodal and infranodal conduction, offering a non-invasive alternative to permanent pacing.

Limitations

Single patient case report
No clear guidelines available regarding the dosing of theophylline for painful LBBB
High rates of drug interactions with commonly used medications
Potential proarrhythmic and gastrointestinal side effects of theophylline
Single case report (n=1)
No clear guidelines available regarding the dosing of theophylline for this indication
High rates of medication interactions with theophylline requiring detailed regimen review

Implication

May offer a non-invasive option for painful LBBB; hypothesis-generating and requires prospective validation.

Abstract

Key Teaching Points•Pathophysiology of painful left bundle branch block (LBBB) is yet to be understood; current hypotheses state ventricular dyssynchrony and/or increased cardiac sensitivity contribute to symptom development.•Diagnosis of painful LBBB must include ruling out ischemic etiology, with subtle hints on electrocardiogram including inferior QRS axis and S/T ratio <1.8 suggestive of diagnosis.•Treatment of painful LBBB has mainly been by permanent pacing or pharmacological sinus node suppression.•Management with theophylline may be considered if other medical management strategies have failed or invasive management with pacemaker is not desired. •Pathophysiology of painful left bundle branch block (LBBB) is yet to be understood; current hypotheses state ventricular dyssynchrony and/or increased cardiac sensitivity contribute to symptom development.•Diagnosis of painful LBBB must include ruling out ischemic etiology, with subtle hints on electrocardiogram including inferior QRS axis and S/T ratio <1.8 suggestive of diagnosis.•Treatment of painful LBBB has mainly been by permanent pacing or pharmacological sinus node suppression.•Management with theophylline may be considered if other medical management strategies have failed or invasive management with pacemaker is not desired.

Discussion

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Cite This Study

Amir et al. (2023) conducted a case report in Painful left bundle branch block (LBBB) (n=1). Oral theophylline was evaluated on Resolution of chest pain during routine activities. Oral theophylline 100 mg twice daily resulted in complete resolution of chest pain during routine activities at 1-month and 3-month follow-ups in a 71-year-old man with painful LBBB.

synapsesocial.com/papers/6a7bdc82073f483584df9913 https://doi.org/10.1016/j.hrcr.2023.02.017

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Oral theophylline for treatment of painful left bundle branch block

Figures

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Oral theophylline for treatment of painful left bundle branch block

Figures

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

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