Ticagrelor-Associated Conduction Disorder: A Case Report and Review of the Literature

Abstract

A 47-year-old female presented to emergency clinic due to non-ST-elevation myocardial infarction (NSTEMI). After receiving acetylsalicylic acid, a loading dose of ticagrelor 180 mg and intravenous unfractionated heparin, she underwent successful placement of drug eluting stent on the distal part of non-dominant left circumflex artery. The patient had no pre-existing atrioventricular (AV) block and did not use AV blocking agent. Approximately 10 h after taking a loading dose of ticagrelor, baseline normal rhythm degenerated to the first and then complete AV block, with mild dizziness. Following cessation of ticagrelor, cardiac rhythm returned to normal level within 2 days. The close monitoring of patients after starting ticagrelor is imperative, so ticagrelor may result in advanced conduction disorders. Here, we report a patient who developed various types of AV block associated with the ticagrelor taken during successful percutaneous coronary intervention for NSTEMI. We also reviewed the literature on the association between ticagrelor use and conduction abnormalities.

A rare case of late-onset ticagrelor-induced sinus arrest

“…Ticagrelor-induced bradycardia and its reversal has been reported in several case reports. [5][6][7][8] In the PLATO trial, ventricular pauses of more than 3 s and more than 5 s were noted in 5.8% and 2.0% of patients, respectively, in first week. After one month, 2.1% and 0.8% of patients developed ventricular pauses >3 s and >5 s, respectively.…”

Syncope After Percutaneous Coronary Intervention

“…Such pauses were mostly asymptomatic and there was no difference in the incidence of syncope and the need for a permanent pacemaker between the 2 groups. Yurtdas et al summarized 9 case reports of ticagrelor-induced bradyarrhythmia, and these patients had preexisting first degree AVB or bundle branch block with concurrent use of AVN-blocking agents. Almost all cases of ticagrelor-induced bradyarrhythmia occurred within the first few days after administering ticagrelor except for 1 patient who presented with Mobitz type II AVB 6 months after taking ticagrelor .…”

“…Yurtdas et al summarized 9 case reports of ticagrelor-induced bradyarrhythmia, and these patients had preexisting first degree AVB or bundle branch block with concurrent use of AVN-blocking agents. Almost all cases of ticagrelor-induced bradyarrhythmia occurred within the first few days after administering ticagrelor except for 1 patient who presented with Mobitz type II AVB 6 months after taking ticagrelor . After switching to clopidogrel, the bradyarrhythmias spontaneously resolved, with the exception of 1 patient who required a permanent pacemaker …”

“…Almost all cases of ticagrelor-induced bradyarrhythmia occurred within the first few days after administering ticagrelor except for 1 patient who presented with Mobitz type II AVB 6 months after taking ticagrelor . After switching to clopidogrel, the bradyarrhythmias spontaneously resolved, with the exception of 1 patient who required a permanent pacemaker …”