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Flecainide-induced wide complex QRS tachycardia: A case report and review of the literature
G Model
EURGER-819; No. of Pages 2 European Geriatric Medicine xxx (2016) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Letter to the editor Flecainide-induced wide complex QRS tachycardia: A case report and review of the literature
A R T I C L E I N F O
Keywords: Flecainide Flutter Wide QRS tachycardia
Flecainide-induced tachycardia is a life-threatening condition, which has rarely been observed. We described a case occurring in an elderly patient. Flecainide is a class 1C anti-arrhythmic drug indicated as a first line treatment of atrial fibrillation (AF) [1]. AF is frequent in elderly people [2] thus flecainide is often prescribed [3]. Wide QRS tachycardia is a life-threatening situation requiring prompt management. An 83-year-old alert woman was admitted to the emergency department (ED) for syncope. Her previous medical history
revealed paroxysmal AF treated by flecainide for the past 4 years. She did not take any other medication. Her loss of consciousness was sudden and brief. On admission, consciousness and blood pressure were normal, heart rate varied from 72 to 150 beats/min. Her ECG (Fig. 1) showed an aspect of regular 1/1 wide complex QRS tachycardia with spontaneous return to sinus rhythm with narrow QRS (Fig. 2). A flecainide-induced atrial flutter with functional bundle branch block was diagnosed. Biology was normal. Flecainide was withdrawn, a progressive disappearance of the tachycardia occurred in 12 hours. Cardiac echography did not show abnormalities. The patient was discharged home with dabigatran and bisoprolol. The AFFIRM study did not show any difference in mortality between sinus rhythm restoration and rate control [4]. Studies in patients without structural cardiac abnormalities have not shown an increased mortality associated with this drug [5,6]. Flecainide is thus a safe option in the treatment of AF. However, precautions should be observed in the prescription of flecainide in case of intraventricular conduction delay [1]. Flecainide has been tested in the prevention of ventricular premature depolarizations in post-myocardial infarction but an increased cardiac mortality (2.5 fold) was found [7].
Fig. 1. ECG during wide complex QRS tachycardia (frequency 150/min) at the admission of a patient in the Emergency Department for syncope. http://dx.doi.org/10.1016/j.eurger.2016.11.003 1878-7649/ß 2016 Published by Elsevier Masson SAS.
Please cite this article in press as: Le Conte P, et al. Flecainide-induced wide complex QRS tachycardia: A case report and review of the literature. Eur Geriatr Med (2016), http://dx.doi.org/10.1016/j.eurger.2016.11.003
G Model
EURGER-819; No. of Pages 2 Letter to the editor / European Geriatric Medicine xxx (2016) xxx–xxx
2
Fig. 2. Sinus rhythm ECG at the admission of a patient in the Emergency Department (observed between the episodes of wide complex QRS tachycardia).
However, a retrospective study found an increased sudden cardiac death incidence or pro arrhythmic events in AF patients under flecainide [8]. This drug might provoke ventricular tachycardia (VT) [9]. In our patient, atrial activity could best be seen in lead V5 (arrow on Fig. 1). A case series of flecainide-induced atrial flutter has been published [10], two patients were treated by cardioversion, one by beta-blockers and one did not need any treatment. Faced with a wide QRS tachycardia in a patient taking flecainide, the physician should first appreciate the overall tolerance. In case of hemodynamic instability, a defibrillation should be carried out [10]. If not, in-depth analysis of the ECG with particular attention to p waves should be done. In case of welltolerated VT, perfusion of hypertonic sodium bicarbonate could be tested because its efficacy has been demonstrated [11,12]. This effect could be related to the efficacy of bicarbonates used to manage intoxication by membrane stabilizing agents. In case of well-tolerated flutter, a monitored observation with cessation of flecainide, and, if necessary beta-blockers to slow down the conduction, is enough in most cases. In conclusion, flecainide-induced wide QRS tachycardia is a rare but confusing syndrome that requires a particular attention. Regardless of the rhythm disorder, the drug must be definitively withdrawn. Disclosure of interest The authors declare that they have no competing interest. References [1] Camm AJ, Lip GYH, De Caterina R, Savelieva I, Atar D, Hohnloser SH, et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation–developed with the special contribution of the European Heart Rhythm Association. Eur Eur Pacing Arrhythm Card Electrophysiol J Work Groups Card Pacing Arrhythm Card Cell Electrophysiol Eur Soc Cardiol 2012;14:1385–413. http://dx.doi.org/10.1093/europace/eus305. [2] Perrenoud J-J. Atrial fibrillation (part 1). Eur Geriatr Med n.d.;2:26–30. doi:10.1016/j.eurger.2010.11.009. [3] Perrenoud J-J. Atrial fibrillation (part 2). Eur Geriatr Med n.d.;2:93–101. doi:10.1016/j.eurger.2010.12.003.
[4] Steinberg JS, Sadaniantz A, Kron J, Krahn A, Denny DM, Daubert J, et al. Analysis of cause-specific mortality in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. Circulation 2004;109:1973–80. http:// dx.doi.org/10.1161/01.CIR.0000118472.77237.FA. [5] Aliot E, Capucci A, Crijns HJ, Goette A, Tamargo J. Twenty-five years in the making: flecainide is safe and effective for the management of atrial fibrillation. Eur Eur Pacing Arrhythm Card Electrophysiol J Work Groups Card Pacing Arrhythm Card Cell Electrophysiol Eur Soc Cardiol 2011;13:161–73. http:// dx.doi.org/10.1093/europace/euq382. [6] Andersen SS, Hansen ML, Gislason GH, Schramm TK, Folke F, Fosbøl E, et al. Antiarrhythmic therapy and risk of death in patients with atrial fibrillation: a nationwide study. Eur Eur Pacing Arrhythm Card Electrophysiol J Work Groups Card Pacing Arrhythm Card Cell Electrophysiol Eur Soc Cardiol 2009;11:886– 91. http://dx.doi.org/10.1093/europace/eup119. [7] The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med 1989;321:406–12. http://dx.doi.org/10.1056/NEJM198908103210629. [8] Almroth H, Andersson T, Fengsrud E, Friberg L, Linde P, Rosenqvist M, et al. The safety of flecainide treatment of atrial fibrillation: long-term incidence of sudden cardiac death and proarrhythmic events. J Intern Med 2011;270:281– 90. http://dx.doi.org/10.1111/j.1365-2796.2011.02395.x. [9] Courand P-YN, Sibellas F, Ranc S, Mullier A, Kirkorian G, Bonnefoy E. Arrhythmogenic effect of flecainide toxicity. Cardiol J 2013;20:203–5. http:// dx.doi.org/10.5603/CJ.2013.0035. [10] Taylor R, Gandhi MM, Lloyd G. Tachycardia due to atrial flutter with rapid 1:1 conduction following treatment of atrial fibrillation with flecainide. BMJ 2010;340:b4684. http://dx.doi.org/10.1136/bmj.b4684. [11] Keyler DE, Pentel PR. Hypertonic sodium bicarbonate partially reverses QRS prolongation due to flecainide in rats. Life Sci 1989;45:1575–80. [12] Goldman MJ, Mowry JB, Kirk MA. Sodium bicarbonate to correct widened QRS in a case of flecainide overdose. J Emerg Med 1997;15:183–6.
a
P. Le Contea,*, N. Mallietb, G. Chapeletc, D. Trewicka Emergency Medicine, University Hospital of Nantes, 44035 Nantes cedex 01, France b Cardiology Department, University Hospital of Nantes, 44035 Nantes cedex 01, France c Geriatric Department, University Hospital of Nantes, 44035 Nantes cedex 01, France
*Corresponding author. Tel.: +33 2 40 08 39 34; fax: +33 2 40 08 46 54 E-mail address: [email protected] (P. Le Conte) Available online xxx
Please cite this article in press as: Le Conte P, et al. Flecainide-induced wide complex QRS tachycardia: A case report and review of the literature. Eur Geriatr Med (2016), http://dx.doi.org/10.1016/j.eurger.2016.11.003
EURGER-819; No. of Pages 2 European Geriatric Medicine xxx (2016) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Letter to the editor Flecainide-induced wide complex QRS tachycardia: A case report and review of the literature
A R T I C L E I N F O
Keywords: Flecainide Flutter Wide QRS tachycardia
Flecainide-induced tachycardia is a life-threatening condition, which has rarely been observed. We described a case occurring in an elderly patient. Flecainide is a class 1C anti-arrhythmic drug indicated as a first line treatment of atrial fibrillation (AF) [1]. AF is frequent in elderly people [2] thus flecainide is often prescribed [3]. Wide QRS tachycardia is a life-threatening situation requiring prompt management. An 83-year-old alert woman was admitted to the emergency department (ED) for syncope. Her previous medical history
revealed paroxysmal AF treated by flecainide for the past 4 years. She did not take any other medication. Her loss of consciousness was sudden and brief. On admission, consciousness and blood pressure were normal, heart rate varied from 72 to 150 beats/min. Her ECG (Fig. 1) showed an aspect of regular 1/1 wide complex QRS tachycardia with spontaneous return to sinus rhythm with narrow QRS (Fig. 2). A flecainide-induced atrial flutter with functional bundle branch block was diagnosed. Biology was normal. Flecainide was withdrawn, a progressive disappearance of the tachycardia occurred in 12 hours. Cardiac echography did not show abnormalities. The patient was discharged home with dabigatran and bisoprolol. The AFFIRM study did not show any difference in mortality between sinus rhythm restoration and rate control [4]. Studies in patients without structural cardiac abnormalities have not shown an increased mortality associated with this drug [5,6]. Flecainide is thus a safe option in the treatment of AF. However, precautions should be observed in the prescription of flecainide in case of intraventricular conduction delay [1]. Flecainide has been tested in the prevention of ventricular premature depolarizations in post-myocardial infarction but an increased cardiac mortality (2.5 fold) was found [7].
Fig. 1. ECG during wide complex QRS tachycardia (frequency 150/min) at the admission of a patient in the Emergency Department for syncope. http://dx.doi.org/10.1016/j.eurger.2016.11.003 1878-7649/ß 2016 Published by Elsevier Masson SAS.
Please cite this article in press as: Le Conte P, et al. Flecainide-induced wide complex QRS tachycardia: A case report and review of the literature. Eur Geriatr Med (2016), http://dx.doi.org/10.1016/j.eurger.2016.11.003
G Model
EURGER-819; No. of Pages 2 Letter to the editor / European Geriatric Medicine xxx (2016) xxx–xxx
2
Fig. 2. Sinus rhythm ECG at the admission of a patient in the Emergency Department (observed between the episodes of wide complex QRS tachycardia).
However, a retrospective study found an increased sudden cardiac death incidence or pro arrhythmic events in AF patients under flecainide [8]. This drug might provoke ventricular tachycardia (VT) [9]. In our patient, atrial activity could best be seen in lead V5 (arrow on Fig. 1). A case series of flecainide-induced atrial flutter has been published [10], two patients were treated by cardioversion, one by beta-blockers and one did not need any treatment. Faced with a wide QRS tachycardia in a patient taking flecainide, the physician should first appreciate the overall tolerance. In case of hemodynamic instability, a defibrillation should be carried out [10]. If not, in-depth analysis of the ECG with particular attention to p waves should be done. In case of welltolerated VT, perfusion of hypertonic sodium bicarbonate could be tested because its efficacy has been demonstrated [11,12]. This effect could be related to the efficacy of bicarbonates used to manage intoxication by membrane stabilizing agents. In case of well-tolerated flutter, a monitored observation with cessation of flecainide, and, if necessary beta-blockers to slow down the conduction, is enough in most cases. In conclusion, flecainide-induced wide QRS tachycardia is a rare but confusing syndrome that requires a particular attention. Regardless of the rhythm disorder, the drug must be definitively withdrawn. Disclosure of interest The authors declare that they have no competing interest. References [1] Camm AJ, Lip GYH, De Caterina R, Savelieva I, Atar D, Hohnloser SH, et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation–developed with the special contribution of the European Heart Rhythm Association. Eur Eur Pacing Arrhythm Card Electrophysiol J Work Groups Card Pacing Arrhythm Card Cell Electrophysiol Eur Soc Cardiol 2012;14:1385–413. http://dx.doi.org/10.1093/europace/eus305. [2] Perrenoud J-J. Atrial fibrillation (part 1). Eur Geriatr Med n.d.;2:26–30. doi:10.1016/j.eurger.2010.11.009. [3] Perrenoud J-J. Atrial fibrillation (part 2). Eur Geriatr Med n.d.;2:93–101. doi:10.1016/j.eurger.2010.12.003.
[4] Steinberg JS, Sadaniantz A, Kron J, Krahn A, Denny DM, Daubert J, et al. Analysis of cause-specific mortality in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. Circulation 2004;109:1973–80. http:// dx.doi.org/10.1161/01.CIR.0000118472.77237.FA. [5] Aliot E, Capucci A, Crijns HJ, Goette A, Tamargo J. Twenty-five years in the making: flecainide is safe and effective for the management of atrial fibrillation. Eur Eur Pacing Arrhythm Card Electrophysiol J Work Groups Card Pacing Arrhythm Card Cell Electrophysiol Eur Soc Cardiol 2011;13:161–73. http:// dx.doi.org/10.1093/europace/euq382. [6] Andersen SS, Hansen ML, Gislason GH, Schramm TK, Folke F, Fosbøl E, et al. Antiarrhythmic therapy and risk of death in patients with atrial fibrillation: a nationwide study. Eur Eur Pacing Arrhythm Card Electrophysiol J Work Groups Card Pacing Arrhythm Card Cell Electrophysiol Eur Soc Cardiol 2009;11:886– 91. http://dx.doi.org/10.1093/europace/eup119. [7] The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med 1989;321:406–12. http://dx.doi.org/10.1056/NEJM198908103210629. [8] Almroth H, Andersson T, Fengsrud E, Friberg L, Linde P, Rosenqvist M, et al. The safety of flecainide treatment of atrial fibrillation: long-term incidence of sudden cardiac death and proarrhythmic events. J Intern Med 2011;270:281– 90. http://dx.doi.org/10.1111/j.1365-2796.2011.02395.x. [9] Courand P-YN, Sibellas F, Ranc S, Mullier A, Kirkorian G, Bonnefoy E. Arrhythmogenic effect of flecainide toxicity. Cardiol J 2013;20:203–5. http:// dx.doi.org/10.5603/CJ.2013.0035. [10] Taylor R, Gandhi MM, Lloyd G. Tachycardia due to atrial flutter with rapid 1:1 conduction following treatment of atrial fibrillation with flecainide. BMJ 2010;340:b4684. http://dx.doi.org/10.1136/bmj.b4684. [11] Keyler DE, Pentel PR. Hypertonic sodium bicarbonate partially reverses QRS prolongation due to flecainide in rats. Life Sci 1989;45:1575–80. [12] Goldman MJ, Mowry JB, Kirk MA. Sodium bicarbonate to correct widened QRS in a case of flecainide overdose. J Emerg Med 1997;15:183–6.
a
P. Le Contea,*, N. Mallietb, G. Chapeletc, D. Trewicka Emergency Medicine, University Hospital of Nantes, 44035 Nantes cedex 01, France b Cardiology Department, University Hospital of Nantes, 44035 Nantes cedex 01, France c Geriatric Department, University Hospital of Nantes, 44035 Nantes cedex 01, France
*Corresponding author. Tel.: +33 2 40 08 39 34; fax: +33 2 40 08 46 54 E-mail address: [email protected] (P. Le Conte) Available online xxx
Please cite this article in press as: Le Conte P, et al. Flecainide-induced wide complex QRS tachycardia: A case report and review of the literature. Eur Geriatr Med (2016), http://dx.doi.org/10.1016/j.eurger.2016.11.003