Canadian Journal of Cardiology

Hydroxychloroquine-Induced Cardiomyopathy: Case Report, Pathophysiology, Diagnosis, and Treatment

Published:August 23, 2014DOI:https://doi.org/10.1016/j.cjca.2014.08.016

      Abstract

      Drug-induced heart and vascular disease remains an important health burden. Hydroxychloroquine and its predecessor chloroquine are medications commonly used in the treatment of systemic lupus erythematosus, rheumatoid arthritis, and other connective tissue disorders. Hydroxychloroquine interferes with malarial metabolites, confers immunomodulatory effects, and also affects lysosomal function. Clinical monitoring and early recognition of toxicity is an important management strategy in patients who undergo long-term treatment with hydroxychloroquine. Retinal toxicity, neuromyopathy, and cardiac disease are recognized adverse effects of hydroxychloroquine. Immediate withdrawal of hydroxychloroquine is essential if toxicity is suspected because of the early reversibility of cardiomyopathy. In addition to recommended ophthalmological screening, regular screening with 12-lead electrocardiogram and transthoracic echocardiography to detect conduction system disease and/or biventricular morphological or functional changes should be considered in hydroxychloroquine-treated patients. Cardiac magnetic resonance imaging and endomyocardial biopsy are valuable tools to provide prognostic insights and confirm the diagnosis of hydroxychloroquine-induced cardiomyopathy. In conclusion, chronic use of hydroxychloroquine can result in an acquired lysosomal storage disorder, leading to a drug-induced cardiomyopathy characterized by concentric hypertrophy and conduction abnormalities associated with increased adverse clinical outcomes and mortality.

      Résumé

      Les maladies cardiaques et vasculaires induites par les médicaments constituent un lourd fardeau pour le système de santé. L’hydroxychloroquine et le médicament qui l’a précédée, la chloroquine, sont fréquemment utilisés dans le traitement du lupus érythémateux systémique, l’arthrite rhumatoïde et d’autres troubles du tissu conjonctif. L’hydroxychloroquine interfère avec les métabolites malariens, a des effets immunomodulatoires et perturbe également le fonctionnement des lysosomes. La surveillance clinique et la détection précoce de la toxicité font partie intégrante d’une importante stratégie de prise en charge chez les patients qui subissent un traitement à long terme par hydroxychloroquine. La toxicité rétinienne, la neuromyopathie et la cardiopathie sont des effets indésirables reconnus de l’hydroxychloroquine. Le retrait immédiat de l’hydroxychloroquine est essentiel si une toxicité est suspectée puisqu’à un stade précoce la cardiomyopathie est réversible. Outre le dépistage ophtalmologique recommandé, le dépistage régulier au moyen de l’électrocardiogramme à 12 dérivations et de l’échocardiographie transthoracique afin de détecter les anomalies du système de conduction et/ou les modifications morphologiques ou fonctionnelles des deux ventricules devrait être envisagé chez les patients traités par hydroxychloroquine. L’imagerie cardiaque par résonance magnétique et la biopsie endomyocardique sont des outils valables pour donner un aperçu du pronostic et confirmer le diagnostic de cardiomyopathie induite par l’hydroxychloroquine. En conclusion, l’utilisation à long terme de l’hydroxychloroquine peut entraîner une maladie de surcharge lysosomale acquise conduisant alors à une cardiomyopathie d’origine médicamenteuse caractérisée par l’hypertrophie concentrique et les anomalies de la conduction associées à l’augmentation des résultats cliniques indésirables et de la mortalité.
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