Amitriptyline-induced ventricular tachycardia: a case report

Abstract

BackgroundIn Bangladesh, each emergency physician faces amitriptyline overdose nearly a day. An acute cardiovascular complication, one of the worst complications is mainly responsible for the mortality in tricyclic overdose. Recently, we managed ventricular tachycardia in a young female presented with an impaired consciousness 10 h after intentionally ingesting 2500 mg amitriptyline. Here, we report it, discuss how the electrocardiography is vital to acknowledge and predict it and its’ complications and also the recent update of the management of it.Case presentationA young married Bangladeshi-Bengali girl, 25-year-old, having a history of disharmony with her husband, came with an impaired consciousness after intentionally ingesting 2500 mg amitriptyline about 10 h before arrival. There was blood pressure 140/80 mmHg, heart rate 140 beats-per-min, temperature 103 °F, Glasgow coma scale 10/15, wide complex tachycardia with QRS duration of 178 ms in electrocardiography, blood pH 7.36. Initially, treated with 100 ml 8.4% sodium bicarbonate. After that, QRS duration came to 100 ms in electrocardiography within 10 min of infusion. To maintain the pH 7.50–7.55 over the next 24 h, the infusion of 8.4% sodium bicarbonate consisting of 125 ml dissolved in 375 ml normal saline was started and titrated according to the arterial blood gas analysis. Hence, a total dose of 600 mmol sodium bicarbonate was given over next 24 h. In addition to this, gave a 500 ml intravenous lipid emulsion over 2 h after 24 h of admission as she did not regain her consciousness completely. Afterward, she became conscious, though, in electrocardiography, ST/T wave abnormality persisted. So that, we tapered sodium bicarbonate infusion slowly and stopped it later. At the time of discharge, she was by heart rate 124/min, QRS duration 90 ms in electrocardiogram along with other normal vital signs.ConclusionDiagnosis of amitriptyline-induced ventricular tachycardia is difficult when there is no history of an overdose obtained. Nevertheless, it should be performed in the clinical background and classic electrocardiographic changes and wise utilization of sodium bicarbonate, intravenous lipid emulsion, and anti-arrhythmic drugs may save a life.

Use of Disproportionality Analysis to Identify Previously Unknown Drug-Associated Causes of Cardiac Arrhythmias Using the Food and Drug Administration Adverse Event Reporting System (FAERS) Database

“…Medications causing QTc-prolongation are used in both inpatient and outpatient settings and have been thoroughly studied. 1,[5][6][7] While drug-induced QTc-prolongation is recognized due to the potential for Torsades de Pointes (TdP), 7 literature for many other drug-induced arrhythmias is limited to case reports [8][9][10][11][12] outside of drug-induced arrhythmia reviews with atrial fibrillation 13 and bradyarrhythmias. [14][15][16] A newly published review of drug-induced arrhythmias did add further to the literature by including a section on atrioventricular nodal reentrant tachycardia.…”

Amitriptyline intoxication in bullfrogs causes widening of QRS complexes in electrocardiogram

“…The neurological symptoms of amitriptyline intoxication include lethargy, coma, convulsion and bilateral loss of light reflexes [4]. In addition to the common cardiovascular abnormalities, such as sinus tachycardia and ventricular arrhythmias, patients with amitriptyline intoxication often show the widening of QRS complexes in electrocardiogram (ECG) [4,25], which eventually leads to fatal cardiac arrest. Using rabbit or canine models, earlier studies revealed the ECG abnormalities caused by different doses of amitriptyline to determine its cardiotoxicity [11,27,32].…”

A Case of Amitriptyline-induced Myocarditis

“…This is due to its effect on atrioventricular conduction through the blockage of fast sodium channels and the inhibition of potassium channels [ 9 ]. Without intervention, fatal dysrhythmias, such as bradycardia with second or third-degree heart block, asystole, and even sudden cardiac death may occur [ 8 - 10 ].…”