i c a l r& E xpeime l i n ntal Journal of Clinical ...€¦ · Amiodarone Induced Variety of ECG...
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Amiodarone Induced Variety of ECG Changes - A Beginners ECG Delight Vikas Singh * , Pramod Kumar, Ajay K Sinha, Kumar Vaibhav Vikash, Anand Gopal and Manish Gunjan Paras HMRI Hospital, Patna, Bihar India * Corresponding author: Vikas Singh, Paras HMRI Hospital, Patna, Bihar India, Tel: +91-9661803767; E-mail: [email protected] Received date: April 12, 2015; Accepted date: July 8, 2015; Published date: July 15, 2015 Copyright: ©2015 Singh V, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abstract We present here the case of a middle aged male with baseline bifascicular block, who continued on more than the prescribed doses of amiodarone and presented with ECG changes which are described in association with amiodarone toxicity. The interesting part is the marked prolongation of QT and PR interval and 2:1 AV block as well as wenckebach on the initial ECG which largely normalized over 72 hour on stopping the drug. Case Report A 40 year non-diabetic, non-hypertensive male; diagnosed case of Dilated Cardiomyopathy was on Tab Amiodarone for one episode of documented ventricular tachycardia. He had RBBB with LAHB on baseline ECG with normal PR interval and normal QT. The patient was unwilling for any device on financial grounds and continued on medical therapy. Amiodarone was prescribed in maintenance dose of 200 mg OD, but somehow he continued to take it in doses of 200 mg thrice daily. The patient presented back after 2 months with generalized weakness. Pulse rate at presentation was 40 bpm and the ECG done showed bifascicular block with 2:1 AV Block and intermittent Wenkebach phenomenon involving 3 cycles (Figure 1). QT interval and PR interval were markedly prolonged being 540 ms and 440 ms respectively. The patient was kept under observation and amiodarone stopped. Three days later, the ECG was much improved with sinus rhythm, PR interval of 240 ms and QT interval of 510 ms (Figure 2). Discussion There are numerous toxins and drugs that can cause, in overdose, electrocardiogram (ECG) changes, the diagnosis of abnormal ECGs encountered in a specific toxicity can challenge experienced physicians [1,2]. Amiodarone is one of the more commonly prescribed drugs in a cardiac setup3. It is categorized as a class III antiarrythmic agent [3], and prolongs phase 3 of the cardiac action potential. Amiodarone also shows beta blocker-like and potassium channel blocker-like actions on the SA and AV nodes, and slows intra-cardiac conduction of the cardiac action potential, via sodium-channel effects. It has numerous cardiac and extracardiac side-effects. Common ECG abnormalities with Amiodarone include Sinus Bradycardia, QT prolongation [4] and First degree AV Block. Further toxicity leads to type 1 and 2 second degree AV Block and complete heart block (in less than 2% of patients). Other uncommon side effects include Torsades de Pointes [5] and asystole. Figure 1: ECG at presentation showing RBBB, LAHB, marked bradycardia, 2:1 block in the initial part of the strip and wenkebach phenomenon in the last 3 QRS complexes. QT interval is markedly prolonged. Singh et al., J Clin Exp Cardiolog 2015, 6:7 DOI: 10.4172/2155-9880.1000391 Case Report Open Access J Clin Exp Cardiolog ISSN:2155-9880 JCEC, an open access journal Volume 6 • Issue 7 • 1000391 Journal of Clinical & Experimental Cardiology J o u r n a l o f C l i n i c a l & E x p e r i m e n t a l C a r d i o l o g y ISSN: 2155-9880
Transcript of i c a l r& E xpeime l i n ntal Journal of Clinical ...€¦ · Amiodarone Induced Variety of ECG...
Amiodarone Induced Variety of ECG Changes - A Beginners ECG DelightVikas Singh*, Pramod Kumar, Ajay K Sinha, Kumar Vaibhav Vikash, Anand Gopal and Manish Gunjan
Paras HMRI Hospital, Patna, Bihar India*Corresponding author: Vikas Singh, Paras HMRI Hospital, Patna, Bihar India, Tel: +91-9661803767; E-mail: [email protected]
Received date: April 12, 2015; Accepted date: July 8, 2015; Published date: July 15, 2015
Copyright: ©2015 Singh V, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricteduse, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
We present here the case of a middle aged male with baseline bifascicular block, who continued on more thanthe prescribed doses of amiodarone and presented with ECG changes which are described in association withamiodarone toxicity. The interesting part is the marked prolongation of QT and PR interval and 2:1 AV block as wellas wenckebach on the initial ECG which largely normalized over 72 hour on stopping the drug.
Case ReportA 40 year non-diabetic, non-hypertensive male; diagnosed case of
Dilated Cardiomyopathy was on Tab Amiodarone for one episode ofdocumented ventricular tachycardia. He had RBBB with LAHB onbaseline ECG with normal PR interval and normal QT. The patientwas unwilling for any device on financial grounds and continued onmedical therapy. Amiodarone was prescribed in maintenance dose of200 mg OD, but somehow he continued to take it in doses of 200 mgthrice daily. The patient presented back after 2 months withgeneralized weakness. Pulse rate at presentation was 40 bpm and theECG done showed bifascicular block with 2:1 AV Block andintermittent Wenkebach phenomenon involving 3 cycles (Figure 1).QT interval and PR interval were markedly prolonged being 540 msand 440 ms respectively. The patient was kept under observation andamiodarone stopped. Three days later, the ECG was much improvedwith sinus rhythm, PR interval of 240 ms and QT interval of 510 ms(Figure 2).
DiscussionThere are numerous toxins and drugs that can cause, in overdose,
electrocardiogram (ECG) changes, the diagnosis of abnormal ECGsencountered in a specific toxicity can challenge experienced physicians[1,2]. Amiodarone is one of the more commonly prescribed drugs in acardiac setup3. It is categorized as a class III antiarrythmic agent [3],and prolongs phase 3 of the cardiac action potential. Amiodarone alsoshows beta blocker-like and potassium channel blocker-like actions onthe SA and AV nodes, and slows intra-cardiac conduction of thecardiac action potential, via sodium-channel effects.
It has numerous cardiac and extracardiac side-effects. CommonECG abnormalities with Amiodarone include Sinus Bradycardia, QTprolongation [4] and First degree AV Block. Further toxicity leads totype 1 and 2 second degree AV Block and complete heart block (in lessthan 2% of patients). Other uncommon side effects include Torsadesde Pointes [5] and asystole.
Figure 1: ECG at presentation showing RBBB, LAHB, markedbradycardia, 2:1 block in the initial part of the strip and wenkebachphenomenon in the last 3 QRS complexes. QT interval is markedlyprolonged.
Singh et al., J Clin Exp Cardiolog 2015, 6:7 DOI: 10.4172/2155-9880.1000391
Case Report Open Access
J Clin Exp CardiologISSN:2155-9880 JCEC, an open access journal
Volume 6 • Issue 7 • 1000391
Journal of Clinical & Experimental CardiologyJo
urna
l of C
linica
l & Experimental Cardiology
ISSN: 2155-9880
Figure 2: ECG three days later showing sinus rhythm with firstdegree AV Block (PR 240 ms), RBBB, LAHB.
References1. Gordon B (2006) Cardiovascular drugs, In: Harris CR (ed.) The
Toxicology Handbook for Clinicians. Mosby Elsevier, Philadelphia, USA,pp. 61-75.
2. Hohnloser SH, Klingenheben T, Singh BN (1994) Amiodarone-associated proarrhythmic effects. A review with special reference totorsade de pointes tachycardia. Ann Intern Med 121: 529-535.
3. Daoud EG, Strickberger SA, Man KC, Goyal R, Deeb GM, et al. (1997)Preoperative amiodarone as prophylaxis against atrial fibrillation afterheart surgery. N Engl J Med 337: 1785-1791.
4. Roden DM (2004) Drug-induced prolongation of the QT interval. N EnglJ Med 350: 1013-1022.
5. Yap YG, Camm AJ (2003) Drug induced QT prolongation and torsadesde pointes. Heart 89: 1363-1372.
Citation: Singh V, Kumar P, Sinha AK, Vikash KV, Gopal A, et al. (2015) Amiodarone Induced Variety of ECG Changes - A Beginners ECGDelight. J Clin Exp Cardiolog 6: 391. doi:10.4172/2155-9880.1000391
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J Clin Exp CardiologISSN:2155-9880 JCEC, an open access journal
Volume 6 • Issue 7 • 1000391
