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Drug-Induced Arrhythmias: A Scientific Statement From the American Heart Association
TAKE-HOME MESSAGE
- Many medications can be associated with arrhythmias, and it is important for clinicians to recognize the possibility that an arrhythmia may be drug-induced. This statement from the American Heart Association used a comprehensive literature search to provide an overview of current knowledge and recommendations.
- This scientific statement provides important information to help clinicians recognize drug-induced arrhythmias promptly to improve patient management.
abstract
This abstract is available on the publisher's site.
Access this abstract nowMany widely used medications may cause or exacerbate a variety of arrhythmias. Numerous antiarrhythmic agents, antimicrobial drugs, psychotropic medications, and methadone, as well as a growing list of drugs from other therapeutic classes (neurological drugs, anticancer agents, and many others), can prolong the QT interval and provoke torsades de pointes. Perhaps less familiar to clinicians is the fact that drugs can also trigger other arrhythmias, including bradyarrhythmias, atrial fibrillation/atrial flutter, atrial tachycardia, atrioventricular nodal reentrant tachycardia, monomorphic ventricular tachycardia, and Brugada syndrome. Some drug-induced arrhythmias (bradyarrhythmias, atrial tachycardia, atrioventricular node reentrant tachycardia) are significant predominantly because of their symptoms; others (monomorphic ventricular tachycardia, Brugada syndrome, torsades de pointes) may result in serious consequences, including sudden cardiac death. Mechanisms of arrhythmias are well known for some medications but, in other instances, remain poorly understood. For some drug-induced arrhythmias, particularly torsades de pointes, risk factors are well defined. Modification of risk factors, when possible, is important for prevention and risk reduction. In patients with nonmodifiable risk factors who require a potentially arrhythmia-inducing drug, enhanced electrocardiographic and other monitoring strategies may be beneficial for early detection and treatment. Management of drug-induced arrhythmias includes discontinuation of the offending medication and following treatment guidelines for the specific arrhythmia. In overdose situations, targeted detoxification strategies may be needed. Awareness of drugs that may cause arrhythmias and knowledge of distinct arrhythmias that may be drug-induced are essential for clinicians. Consideration of the possibility that a patient's arrythmia could be drug-induced is important.
Additional Info
Drug-Induced Arrhythmias: A Scientific Statement From the American Heart Association
Circulation 2020 Sep 15;[EPub Ahead of Print], JE Tisdale, MK Chung, KB Campbell, M Hammadah, JA Joglar, J Leclerc, B RajagopalanFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
The recently released scientific statement from the American Heart Association on drug-induced arrhythmias1 is a resource that cardiologists and researchers will find extremely valuable as a reference and one that they will want to print and keep close at hand. The statement is filled with practical advice on the recognition and management of an iatrogenic problem that is increasingly recognized for its morbidity and mortality. Its seven tables concisely summarize data on the drugs that are known to cause atrial tachycardia, sinus bradycardia/AV block, atrial fibrillation/flutter, AV node reentrant tachycardia, monomorphic ventricular tachycardia, Brugada syndrome, and torsades de pointes (TdP). Where possible, the authors included an estimate of arrhythmia incidence/relative risk and a presumed arrhythmogenic mechanism for the drugs. For a consensus statement, the document is remarkably current and even includes a discussion of the arrhythmogenic potential of drugs now being used to treat COVID-19.
Because the authors recognize the challenges that clinicians face when trying to manage so much information, they included a section on the current state of “clinical decision support” programs that are designed to detect and mitigate the risk of arrhythmias induced by QT-prolonging drugs. Hopefully, the statement will serve as a catalyst for clinicians and researchers to examine and understand the pathogenesis and risk factors for the other forms of drug-induced arrhythmias, as they have for TdP.
This timely statement captures the important elements of a rapidly growing scientific discipline that began in the 1980s with observations of “proarrhythmia.”2 It recalls the pivotal research with quinidine,3 terfenadine,4 and the potent sodium channel blockers (encainide and flecainide) that were in the NIH-sponsored Cardiac Arrhythmia Suppression Trial (CAST)5 and have taught us both humility and a greater understanding of human pathophysiology.
This publication should be considered a wake-up call signaling the need for greater awareness and recognition of this problem. It is probably worth noting that, currently, there is no ICD-10 code for drug-induced arrhythmia. With hundreds of commonly prescribed medicines capable of inducing arrhythmias and the average American taking 12 prescription drugs each year, we should always keep drug-induced arrhythmia in the differential diagnosis of patients with arrhythmias and refer to this document regularly.
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