41. Looking at Lyme carditis with Dr. Adrian Baranchuk
Preventing complications through early diagnosis.
In today’s podcast Sarah explores Lyme carditis with Dr. Adrian Baranchuk, a cardiologist from Kingston, Ontario. Lyme carditis is inflammation of the heart and can cause lightheadedness, palpitations, fainting, chest pain and shortness of breath. In severe cases, it can be fatal.
Dr. Baranchuk tells Sarah he has now seen 16 patients with Lyme carditis. He met his first patient when a physician in a nearby hospital requested transfer of a young 14 year old patient with something called AV block, a disruption of the electrical pathway that stimulates the heart to contract.
Treating the infection
The young patient had a life saving temporary pacemaker inserted, and the transferring physician mentioned that she had sent blood work for Lyme disease. This prompted Dr. Baranchuk to investigate something called Lyme carditis and question whether antibiotics might resolve the heart block and prevent the need for a permanent pacemaker to be inserted in this young patient. He did initiate antibiotics, and within one week, the patient had a completely normal electrical system in his heart. The temporary pacemaker was removed, and his cardiac stress test showed normal results.
“The recent publication in Current Problems in Cardiology of our first series of patients, properly diagnosed and treated for Lyme carditis…none of them received a permanent pacemaker…(on average, after 2.4 years they have) normal structural heart, no consequences of what happened.”
Dr. Adrian Baranchuk
ECG in the ER
Since then, a protocol was developed and subsequently replicated and adopted by the CDC to diagnose and treat Lyme carditis. He reiterates that a 12 lead ECG should be done on all patients with Lyme disease or suspicion of Lyme disease in the Emergency Room. Although patients who are older or have coronary artery disease may have a degree of AV block that is not caused by Lyme disease, Lyme disease should always be considered in patients who are younger and otherwise healthy.
Prevalence in children
How common is Lyme carditis in children? Previous estimates of Lyme carditis were 2-4% of all Lyme patients, but Dr. Baranchuk notes that a recent study in children found a prevalence of up to 10%. More recently, one of his colleagues sent him a picture of a rash his daughter had, and Dr. Baranchuk advised them to go immediately to the hospital to get antibiotics. Sarah is encouraged by these examples of “learning in action”, where increased knowledge, curiosity and awareness continue to guide and transform practice.
“The heart gets involved in Lyme disease way more often than what we knew ten years ago…a very recent study in the States in kids has shown that the prevalence is up to 10%.”
Dr. Adrian Baranchuk
When to suspect Lyme carditis
Dr. Baranchuk helped to develop a tool called the Suspicious Index in Lyme Carditis (SILC) which looks at the constitutional symptoms (COSTAR): outdoor activities, sex (male to female ratio of Lyme carditis is 6-8 males for every female), tick bite, age (less than 50) and rash (COSTAR). If a patient’s COSTAR score is over 3 points, Lyme should be considered at the top of the list of possible diagnoses. Such patients with high degree AV block should be admitted to the hospital with continuous heart monitoring, Lyme bloodwork and IV antibiotics. Dr. Baranchuk points out that antibiotics should be started before the Lyme blood work results because the consequences of untreated Lyme carditis are much worse than the risk of antibiotics. He also explains that some patients with Lyme carditis have a negative blood test for Lyme disease.
“Obtaining a simple inexpensive 12 lead ecg, which shows the electrical component of the heart, should be mandatory for all people with a diagnosis of Lyme disease or suspicion of Lyme disease in the emergency room.”
Dr. Adrian Baranchuk
Treating the root cause
Dr. Barunchuk describes the first 4-6 weeks of Lyme infection as early disseminated Lyme. He explains that 90% of patients present with Lyme carditis, and 10% present with myocarditis, and that untreated, both of these conditions can be life threatening. He also points to a recent publication in Current Problems in Cardiology in which none of the patients that were properly diagnosed and treated for Lyme carditis required a permanent pacemaker.
Effective early treatment
Dr. Baranchuk describes the case of a patient who had presented to another hospital with symptoms of Lyme disease, along with a shut down of the electrical system of her heart. A permanent pacemaker was inserted and she was tested for Lyme disease. Her Lyme test came back positive and she was treated with 4 weeks of antibiotics. Upon testing, her pacemaker had initially been active 35-50% of the time, but after antibiotics that number reduced to less than 1% of the time. In this case and another similar case, the pacemakers were removed and tests done on the leads that had been in the patients’ hearts showed no evidence of Lyme bacteria.
“In our experience, every person presenting with either a tick bite or a rash and complete heart block, that is always Lyme carditis.”
Dr. Adrian Baranchuk
Ongoing infection
In contrast to the negative test result found on these pacemaker leads, Dr. Barunchuk points out that autopsies done on some patients with persistent Lyme disease showed evidence of Lyme bacteria in their brains, even though they had received multiple courses of antibiotics. He also explains that the scientific community now recognizes that, as with COVID, some patients with Lyme disease continue to have symptoms after antibiotic treatment. He is hopeful that new treatments will be discovered to help these patients.
“The patient who has advanced high degree AV block…you suspect because you have a COSTAR (risk rating) of more than 3 points that this could be Lyme carditis. So the procedure is…admission of the patient on a telemetry unit…take serology immediately…start IV antibiotics.”
Dr. Adrian Baranchuk
New horizons
Dr. Barunchuk is now turning his efforts toward exploring a chronic model for Lyme carditis for patients with long term symptoms of Lyme disease. Thank you Dr. Baranchuk for sharing your experience and insight regarding Lyme carditis. We look forward to following your work on Lyme carditis as more becomes known about this serious complication of Lyme disease.
“If you have Lyme carditis manifested as a shutdown of the electrical system, and you don’t diagnose it and you don’t treat it, the probabilities of that event resulting in death are quite high.”
Dr. Adrian Baranchuk
- Dr. Adrian Baranchuk, School of Medicine, Queens University
- Suspicious index in Lyme carditis: Systematic review and proposed new risk score
- Clinical Electrocardiography: A Textbook, 5th Edition
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