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Home , Bradycardia, Tachycardia

Br J: first published as 10.1136/hrt.40.10.1149 on 1 October 1978. Downloaded from

British _7ertJournal, 1978, 40, 1149-1152

Use of in - syndrome

ALLEN K. BROWN, ROBERT A. PRIMHAK, AND PAUL NEWTON From the Royal Lancaster Infirmary, Lancaster

SUMMARY Five patients with the bradycardia-tachycardia syndrome have been treated successfully with the amiodarone. Three patients were treated for over nine months and one of these patients had corneal micro deposits. One patient had to be taken off the drug because of side effects. Amiodarone should be tried in patients suffering from the bradycardia-tachycardia syndrome before resorting to cardiac pacing.

Bradycardia-tachycardia syndrome usually reflects Case reports the presence of sinoatrial disease, in which episodes of supraventricular tachycardia complicate sinus CASE 1 bradycardia with or without periods of sinus arrest A 54-year-old man was admitted in September 1974 or . with an acute anterior com- Dizziness, , or convulsions may result plicated by ventricular and atrial fibril- from cerebral ischaemia secondary to bradycardia, lation. He had received for 6 years and tachycardia may cause palpitation, ischaemic previously for essential . In June 1976, cardiac , dyspnoea, and, more rarely, hypo- he was readmitted with bouts of ischaemic cardiac tension and cardiac failure. Systemic emboli may pain associated with periods of rapid atrial fibrilla- occur particularly in patients over 50 years tion followed by at 30 beats a http://heart.bmj.com/ (Rubenstein et al., 1972; Ferrer, 1973). minute. Treatment with digoxin, , and The aetiology of the sick sinus syndrome and the in turn caused sinus bradycardia bradycardia-tachycardia syndrome is often un- associated with faintness and dizziness, and failed known, but associations with coronary to prevent periods of . disease, thyrotoxicosis, , amyloido- Amiodarone 200 mg twice daily was started in sis, diabetes, and cardiac surgery have been reported, July 1976, and was subsequently reduced to 100 mg and there is a rare familial form (British Medical twice daily because of nausea. He has had no further Journal, 1977). bouts of , dizziness, faintness, or palpita- on September 30, 2021 by guest. Protected copyright. Correlation of electrocardiographic rhythm tion and has now taken the drug for 13 months. changes with symptoms over 24-hour periods using Corneal micro deposits were noted 5 months after ambulatory monitoring equipment facilitates diag- starting amiodarone, but have not increased since, nosis of the syndrome, and the combination of im- and have not interfered with vision. The condition planted pacemakers and appropriate antiarrhythmic was explained to the patient who expressed a desire agents has been successful in controlling the clinical to continue with the drug. A 24-hour electrocardio- features. Drug treatment alone is difficult since graphic recording using the Oxford Medilog equip- agents which control the tachycardia may aggravate ment showed no one year after the start the bradycardia and vice versa. The ideal drug of treatment. would be effective in controlling bradycardia and tachycardia without the need for cardiac pacing, CASE 2 and in this communication we report the results of A 73-year-old man was admitted to hospital in July treating 5 patients with the antiarrhythmic agent 1976 with a 3-month history of retrosternal pain amiodarone. variably related to exertion. For 2 days before admission he had suffered from repeated episodes of Received for publication 30 September 1977 dizziness and inability to concentrate, and on one 1149 Br Heart J: first published as 10.1136/hrt.40.10.1149 on 1 October 1978. Downloaded from

1150 A. K. Brown, R. A. Prirnhak, and P. Newton occasion had lost consciousness resulting in a fall CASE 5 and a scalp laceration. He had been treated with A woman aged 47 years was first seen in 1970 with guanethidine and a thiazide for two years paroxysmal supraventricular tachycardia occurring previously. particularly at night. The patient reported On admission his was 180/100 rates at under 40 a minute on other occasions. She mmHg, with a basal midsystolic murmur and the was treated unsuccessfully with courses of pro- electrocardiogram showed left ventricular hyper- pranolol, phenytoin, and , and periods trophy and prolonged bouts of at of sinus bradycardia were seen to be associated with 150 beats a minute, and sinus bradycardia at 40 beats exhaustion and feelings of faintness. In January a minute. The slow rhythm was associated with 1977, her blood pressure was 125/80 and a 24-hour dizziness and feelings of syncope. electrocardiogram showed periods of sinus tachy- Digoxin caused persistent sinus bradycardia and cardia at 130 a minute alternating with sinus brady- verapamil was subsequently tried without altering cardia at 32 a minute and sinus arrest. She was the frequency of the tachycardia and bradycardia. started on amiodarone 200 mg twice daily, with no Amiodarone 200 mg twice daily successfully con- improvement, but on 200 mg three times per day trolled the symptoms, and routine, regular 12 lead she had no cardiac symptoms, and a repeat 24-hour electrocardiograms have shown . A 24- electrocardiogram showed sinus rhythm varying hour electrocardiogram in June 1976 shows sinus between 60 and 84 beats a minute. She complained rhythm with a rate which drops to 46 a minute on of feeling unwell without specific features, and blood occasions with no symptoms. pressure rose to 190/125 mmHg. Amiodarone was stopped after 10 weeks but the blood pressure remained high, and she has been on hypotensive CASE 3 agents since. The palpitation and exhaustion A 48-year-old woman was investigated in September with 1976 for a pyrexial illness. Chest x-ray film showed associated bradycardia have persisted, and she diffuse pulmonary infiltration, and the ESR was is awaiting permanent cardiac pacemaking. 50 mm/hour (Westergren). A diagnosis of allergic alveolitis was made, and she was treated with Discussion prednisolone. In December 1976 she was admitted Amiodarone is a benzofuran derivative which was because of transient loss of consciousness, and a originally introduced as an agent, but has routine electrocardiogram showed the features of subsequently been shown to be valuable in the http://heart.bmj.com/ the bradycardia-tachycardia syndrome with sinus atrial bradycardia at 30 beats a minute coinciding with management of and ventricular A trial of and in the Wolff-Parkinson-White syndrome transient loss of consciousness. propranolol (Rosenbaum et al., 1976). There have been no caused extreme bradycardia and because of previous previous reports of the use of amiodarone in the success in this condition, amiodarone 200 mg twice bradycardia-tachycardia syndrome. daily was started and sinus rhythm was restored, The principal actions of amiodarone are to cause with no further loss of consciousness. relaxation of vascular smooth muscle resulting in a Six weeks later the amiodarone was withdrawn slight fall in systemic vascular resistance with slight on September 30, 2021 by guest. Protected copyright. without return of symptoms and she has remained reduction in systemic blood pressure, and a fall in well subsequently. coronary arterial resistance and improved coronary blood flow. The drug also causes an - CASE 4 resistant bradycardia, and reduces the effects of A man aged 87 years was admitted in October 1976 and sympathetic stimulation without with a 6-week history of transient disturbance of acting as a competitive cx and fi receptor blocking consciousness and short periods of lower sternal agent. Singh and Vaughan Williams (1970) report tight feelings. A 24-hour electrocardiogram using that amiodarone causes prolongation of the duration the Oxford Medilog system showed periods of of the action potential in atrial and ventricular supraventricular tachycardia at 140 per minute muscle with no change in the resting potential, and associated with retrosternal discomfort, and periods amiodarone has been grouped with bretylium as a of sinus bradycardia at 40 a minute coinciding with class 3 antiarrhythmic agent (Olsson et al., 1973; disturbance of conscious level (see Fig.). Treatment Singh and Hauswirth, 1974). The net haemo- with phenytoin made no difference to the clinical dynamic effects of the drug are an increase in features and amiodarone 200 mg twice daily was coronary arterial blood flow, and reduction in left started 3 weeks later with complete abolition of ventricular work and in myocardial oxygen con- symptoms during subsequent 9 months on the drug. sumption owing to the slowing of the heart and to Br Heart J: first published as 10.1136/hrt.40.10.1149 on 1 October 1978. Downloaded from

Use of amiodarone in bradycardia-tachycardia syndrome 1151

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Fig. Twenty-four hour electrocardiogram from case 4 showing supraventricular tachycardia and sinus bradycardia. the reduction in systemic vascular resistance effects. Bradycardia, disorders, skin lesions, (ChArlier et al.,S....1972). photosensitivity, and one case of sensory ataxic There is ample..... evidence of the efficacy of amio- paraesthesiae and tremor have been described darone in the management of arrhythmias, particu- (Lustman and Monsea, 1974), but most concern has larly of supraventricular origin (Van Schepdael and centred on the frequency of corneal micro deposits. Solvay, 1975; Rosenbaum et al., 1976), but its use The deposits, however, are usually found below the has been limited because of concern over side pupil, do not interfere with vision, are reversible, Br Heart J: first published as 10.1136/hrt.40.10.1149 on 1 October 1978. Downloaded from

1152 A. K. Brown, R. A. Primhak, and P. Newton and may be prevented by methylcellulose eye drops syndrome before they are committed to permanent (Francois, 1969; Soussi and Colonna, 1974). cardiac pacemaking. One patient, case 1, has developed corneal micro deposits without interference with vision, and 2 patients have stopped amiodarone. Case 3 has References remained well after 6 weeks on the drug and 1 British Medical3Journal (1977). Sick sinus syndrome. 1, 4-5. patient, case 5, felt generally unwell on amiodarone Charlier, R., Delaunois, G., and Bauthier, J. (1972). Opposite effects of amiodarone and blocking agents on cardiac and her blood pressure rose significantly, so the function under adrenergic stimulation. Arzneimittel drug was withdrawn after 10 weeks. In view of the Forschung, 22, 545-552. usual hypotensive effect of amiodarone, the rise in Ferrer, M. I. (1973). The sick sinus syndrome. Circulation, blood pressure in this patient is surprising and 47, 635-641. Francois, J. (1969). Cornea Verticillata. Documenta Ophthal- unexplained, but may be a coincidental finding and mologica, 27, 235-250. not a true complication of therapy. Lustman, F., and Monsea, G. (1974). Amiodarone and neuro- The most important finding in these 5 patients logical side effects. Lancet, 1, 568. is that none of them developed symptomatic brady- Olsson, S. B., Brorson, L., and Varnauskas, E. (1973). Class 3 antiarrhythmic action in man. Observations from mono- cardia despite taking adequate amiodarone to phasic action potential recordings and amiodarone treat- prevent supraventricular tachycardia. Failure of the ment. British Heart Journal, 35, 1255-1259. drug to produce excessive slowing of the heart may Rosenbaum, M. B., Chiale, P. A., Halpern, M. S., Nau, G. J., reflect improved coronary arterial blood supply Przybylski, J., Levi, R. J., Lazzari, J. O., and Elizari, M. V. relaxation of (1976). Clinical efficacy of amiodarone as an antiarrhythmic because of amiodarone-induced agent. American Journal of , 38, 934-944. smooth muscle in the coronary . The sinus Rubenstein, J., Schulman, C., Yurchak, P., and DeSanctis, R. node is supplied by a single vessel arising from either (1972). Clinical spectrum of the sick sinus syndrome. the right coronary artery or the left circumflex Circulation, 46, 5-13. the sinus Singh, B. N., and Hauswirth, 0. (1974). Comparative artery, and improved blood flow through mechanisms of action of antiarrhythmic drugs. American node artery as a result of amiodarone administration Heart Journal, 87, 367-382. may improve perfusion of the sinus node, and the Singh, B. N., and Vaughan Williams, E. M. (1970). The effect atrial myocardium and interatrial septum which of amiodarone, a new anti-anginal drug, on . the same vessel. In 3 of the British Journal of Pharmacology, 39, 657-667. receive blood supply via Soussi, A., and Colonna, D. (1974). Troubles du rythme 5 patients in this series, ischaemic heart disease is auriculaire et amiodarone. Journal des Agreges, 7, 43.

the probable cause of the bradycardia-tachycardia Van Schepdael, J., and Solvay, H. (1975). L'amiodarone dans http://heart.bmj.com/ syndrome and improved coronary arterial blood le traitment des troubles du rythme cardiagne. Praxis, 64, flow by amiodarone could aid atrial bradycardia in 30-34. these patients. We suggest that amiodarone deserves a trial in Requests for reprints to Dr Allen K. Brown, Royal patients suffering from the bradycardia-tachycardia Lancaster Infirmary, Lancaster LA1 4RP. on September 30, 2021 by guest. Protected copyright.