Unusual Tachycardia After Cocaine Use

Kawji, Mazen M.

doi:10.1001/jamainternmed.2023.1737

JAMA Intern Med

2023

DOI: 10.1001/jamainternmed.2023.1737

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Unusual Tachycardia After Cocaine Use

Mazen M. Kawji

Abstract: This case report presents the electrocardiogram findings of a patient in their 20s with severe midsternal chest pain of several hours’ duration after cocaine use.

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2024

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Cited by 2 publications

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“…In Reply I thank Lin and He for their interest in my case report . Most of their points were already addressed in detail, however.…”

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confidence: 98%

“…Most of their points were already addressed in detail, however. Determining the cause of bidirectional ventricular tachycardia (BVT) was clearly addressed when I stated that “treatment of BVT should consider the cause of the arrhythmia.” Gastric lavage for treatment of aconitine ingestion was also mentioned.…”

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confidence: 99%

“…This was also spelled out in the main body of my report: “Cardioversion is used if the patient is unstable, or if other treatments fail,” and in the take-home points, “Traditional antiarrhythmic agents may fail in terminating BVT. Cardioversion is the last resort.”…”

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Unusual Tachycardia After Cocaine Use—Reply

Kawji

2024

JAMA Intern Med

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COMMENT & RESPONSEIn Reply I thank Lin and He for their interest in my case report. 1 Most of their points were already addressed in detail, however. Determining the cause of bidirectional ventricular tachycardia (BVT) was clearly addressed when I stated that "treatment of BVT should consider the cause of the arrhythmia." 1 Gastric lavage for treatment of aconitine ingestion was also mentioned.Administering oral sodium channel-blockers, such as mexiletine, flecainide, and amiodarone, as suggested by Lin and He, is inappropriate for the treatment of ventricular tachycardia in the acute setting. Intravenous lidocaine and amiodarone may be ineffective. 2,3 Intravenous phenytoin, a potent class 1B (sodium channel-blocker) antiarrhythmic agent was used successfully to treat BVT, as referenced in my report. 3,4 There is no question that immediate electrical cardioversion is indicated in cases of tachyarrhythmias associated with hemodynamic instability, ongoing ischemia, or acute heart failure. This was also spelled out in the main body of my report: "Cardioversion is used if the patient is unstable, or if other treatments fail," and in the take-home points, "Traditional antiarrhythmic agents may fail in terminating BVT. Cardioversion is the last resort." 1 Lin and He took that last sentence of the case report out of context. Electrical cardioversion is effective in terminating BVT. 2,5 Having said that, I agree that electrical cardioversion can precipitate severe rhythm disturbances in patients with severe digitalis toxicity and should be used with caution. 6

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“…In Reply I thank Lin and He for their interest in my case report . Most of their points were already addressed in detail, however.…”

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confidence: 98%

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confidence: 99%

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Unusual Tachycardia After Cocaine Use—Reply

Kawji

2024

JAMA Intern Med

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“…To the Editor We read with great interest a recent case report by Kawji . It reports of a patient with bidirectional ventricular tachycardia (BVT) induced by cocaine use and mentions electrical cardioversion as a last resort, which we find is inappropriate.…”

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Unusual Tachycardia After Cocaine Use

Lin,

2024

JAMA Intern Med

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To the Editor We read with great interest a recent case report by Kawji. 1 It reports of a patient with bidirectional ventricular tachycardia (BVT) induced by cocaine use and mentions electrical cardioversion as a last resort, which we find is inappropriate.Treatment of BVT must first determine its cause. The causes of BVT are divided into toxic and nontoxic. Digoxin intoxication is the most common cause of BVT, but digoxin intoxication is not amenable to cardioversion because it produces calcium overload, which induces delayed after depolarization (DAD). Other causes, including aconite, cocaine, and caffeine intoxication, are all caused by DAD, although the ion imbalance between Na + , K + , and Ca 2+ is different.When BVT is suspected to be an acute phase transition caused by drugs, supportive treatments, such as gastric lavage, gastrointestinal decompression, and continuous kidney replacement therapy, are required to allow the body to excrete toxic alkaloids. In addition, for hemodynamically stable patients, Na + channel blockers can be used according to the mechanism of aconitine-induced arrhythmia; mexiletine, flecainide, and amiodarone may also be effective.Electrical cardioversion may be an alternative treatment for BVT when other antiarrhythmic drugs are ineffective; however, previous experience has shown that cardioversion is rarely effective. 2 When the patient is hemodynamically unstable, direct current cardioversion should be preferred because it is a safer cardioversion method than antiarrhythmic drugs. Timely application of electrical cardioversion has been shown to terminate a variety of cardiac arrhythmias and is believed to work by synergistically activating inactive voltagedependent sodium channels, thereby terminating automaticity. A growing number of case reports and clinical reviews of intoxicated BVT demonstrate limited effectiveness of electrical cardioversion for BVT. 3 This disappointing performance may

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Unusual Tachycardia After Cocaine Use

Abstract: This case report presents the electrocardiogram findings of a patient in their 20s with severe midsternal chest pain of several hours’ duration after cocaine use.

Cited by 2 publications

References 8 publications

Unusual Tachycardia After Cocaine Use—Reply

Unusual Tachycardia After Cocaine Use—Reply

Unusual Tachycardia After Cocaine Use

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