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Flecainide Toxicity Resulting in Pacemaker Latency and Intermittent Failure to Capture.
Am J Case Rep. 2019 Aug 30; 20:1279-1283.AJ

Abstract

BACKGROUND

Flecainide is a class Ic antiarrhythmic agent used in the treatment of supraventricular and ventricular arrhythmias. It is associated with a potent adverse effect profile; however, the effects of flecainide toxicity in the setting of a pacemaker have not been well described. We describe a unique case of flecainide toxicity secondary to acute kidney injury in the setting of a dual-chamber pacemaker, resulting in ventricular capture latency and intermittent failure to capture. CASE REPORT The patient was a 91-year-old female with a history of atrial fibrillation maintained in sinus rhythm on flecainide, who presented complaining of purple visual disturbances and syncope. She was found to be hypotensive and bradycardic, with a heart rate between 30 to 40 beats per minute. Lab work was notable for creatinine at 2.12 mg/dL. A 12-lead ECG demonstrated atrial and ventricular pacing with severely widened QRS complex and a significant latency between the pacemaker ventricular spike and the ventricular capture. The pacemaker was interrogated, revealing a significant increase in ventricular threshold from 0.75 V at 0.5 ms at baseline to 5.0 V at 1 ms to obtain consistent capture. After multiple boluses of IV sodium bicarbonate, the QRS acutely narrowed, latency interval improved, and consistent pacing capture was achieved. The flecainide level drawn on arrival was 3.09 mcg/mL.

CONCLUSIONS

Flecainide increases the ventricular capture threshold for pacemakers. Toxicity in these patients may present with pacemaker ventricular capture latency or failure to capture.

Authors+Show Affiliations

Department of Internal Medicine, University of Kentucky, Lexington, KY, USA.Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA.Department of Emergency Medicine, University of Kentucky, Lexington, KY, USA.Department of Emergency Medicine, University of Kentucky, Lexington, KY, USA.Division of Cardiology, University of Florida - Jacksonville, Jacksonville, FL, USA.Division of Cardiology, University of Florida - Jacksonville, Jacksonville, FL, USA.

Pub Type(s)

Case Reports
Journal Article

Language

eng

PubMed ID

31467262

Citation

Suffredini, John M., et al. "Flecainide Toxicity Resulting in Pacemaker Latency and Intermittent Failure to Capture." The American Journal of Case Reports, vol. 20, 2019, pp. 1279-1283.
Suffredini JM, Rutland J, Akpunonu P, et al. Flecainide Toxicity Resulting in Pacemaker Latency and Intermittent Failure to Capture. Am J Case Rep. 2019;20:1279-1283.
Suffredini, J. M., Rutland, J., Akpunonu, P., Baum, R., Catanzaro, J., & Elayi, C. S. (2019). Flecainide Toxicity Resulting in Pacemaker Latency and Intermittent Failure to Capture. The American Journal of Case Reports, 20, 1279-1283. https://doi.org/10.12659/AJCR.916370
Suffredini JM, et al. Flecainide Toxicity Resulting in Pacemaker Latency and Intermittent Failure to Capture. Am J Case Rep. 2019 Aug 30;20:1279-1283. PubMed PMID: 31467262.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Flecainide Toxicity Resulting in Pacemaker Latency and Intermittent Failure to Capture. AU - Suffredini,John M, AU - Rutland,Joshua, AU - Akpunonu,Peter, AU - Baum,Regan, AU - Catanzaro,John, AU - Elayi,Claude S, Y1 - 2019/08/30/ PY - 2019/8/31/entrez PY - 2019/8/31/pubmed PY - 2020/2/6/medline SP - 1279 EP - 1283 JF - The American journal of case reports JO - Am J Case Rep VL - 20 N2 - BACKGROUND Flecainide is a class Ic antiarrhythmic agent used in the treatment of supraventricular and ventricular arrhythmias. It is associated with a potent adverse effect profile; however, the effects of flecainide toxicity in the setting of a pacemaker have not been well described. We describe a unique case of flecainide toxicity secondary to acute kidney injury in the setting of a dual-chamber pacemaker, resulting in ventricular capture latency and intermittent failure to capture. CASE REPORT The patient was a 91-year-old female with a history of atrial fibrillation maintained in sinus rhythm on flecainide, who presented complaining of purple visual disturbances and syncope. She was found to be hypotensive and bradycardic, with a heart rate between 30 to 40 beats per minute. Lab work was notable for creatinine at 2.12 mg/dL. A 12-lead ECG demonstrated atrial and ventricular pacing with severely widened QRS complex and a significant latency between the pacemaker ventricular spike and the ventricular capture. The pacemaker was interrogated, revealing a significant increase in ventricular threshold from 0.75 V at 0.5 ms at baseline to 5.0 V at 1 ms to obtain consistent capture. After multiple boluses of IV sodium bicarbonate, the QRS acutely narrowed, latency interval improved, and consistent pacing capture was achieved. The flecainide level drawn on arrival was 3.09 mcg/mL. CONCLUSIONS Flecainide increases the ventricular capture threshold for pacemakers. Toxicity in these patients may present with pacemaker ventricular capture latency or failure to capture. SN - 1941-5923 UR - https://www.unboundmedicine.com/medline/citation/31467262/Flecainide_Toxicity_Resulting_in_Pacemaker_Latency_and_Intermittent_Failure_to_Capture_ L2 - https://www.amjcaserep.com/download/index/idArt/916370 DB - PRIME DP - Unbound Medicine ER -