IMAJ • VOL 18 • july 2016 Case Communications

Magnesium-Responsive Polymorphic Ventricular Associated with Alcoholic Hussein Sliman MD, Keren Zissman MD, Jacob Goldstein MD, Moshe Y. Flugelman MD and Yaron Hellman MD

Department of Cardiovascular Medicine, Carmel Medical Center, affiliated with Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel

included untreated hypertension, smoking total bilirubin 4.5 mg/dl, aspartate amino- Key words: alcohol intoxication, polymorphic and alcohol abuse. On physical examination transferase (AST) 245 IU/L, alanine ami- (VT), she appeared anxious and diaphoretic. Her notransferase (ALT) 90 IU/L and gamma- magnesium, holiday heart syndrome systemic blood pressure was 100/60 mmHg glutamyl transferase (GGT) 1578 IU/L. IMAJ 2016; 18: 439–440 with an average heart rate of 90. An elec- The patient was questioned about alco- trocardiogram demonstrated sinus rhythm hol ingestion due to the combination of interrupted by episodes of polymorphic severe electrolyte depletion and abnormal e recently treated a patient with re- non-sustained VT [Figure 1A]. During liver function tests. The patient scored 1/4 W petitive episodes of polymorphic ven- sinus rhythm, the QT interval was markedly on the CAGE questionnaire and added that tricular tachycardia (VT) and a prolonged prolonged [Figure 1B]. Transthoracic echo- she drank five glasses of vodka on the night QT interval following alcoholic binge cardiogram revealed normal ventricular prior to admission. drinking. The VT episodes subsided after function. Due to hypotension and persistent The episodes of polymorphic VT did not empiric administration of intravenous mag- ventricular , coronary angiogra- recur and subsided after the initial magne- nesium. The following case history illus- phy was performed which demonstrated sium infusion. The QT interval was signifi- trates the role of alcohol as a possible etiol- normal coronary arteries. cantly shortened after electrolyte repletion ogy in patients with arrhythmia. Treatment In the ED the patient received intrave- [Figure 1C]. The patient was discharged of this unusual arrhythmia and review of nous amiodarone and metoprolol which did with the recommendation to avoid excessive the literature provide insight into the grow- not affect the VT episodes. The combination drinking and was referred to social services ing problem of alcohol binging. of prolonged QT and polymorphic VT also for further treatment of her alcoholism. prompted administration of intravenous magnesium while laboratory results were PATIENT DESCRIPTION still pending. The patient’s initial lab values COMMENT A 47 year old female presented to the emer- included a sodium level of 132 mEq/L, Alcoholic binge drinking is commonly gency department (ED) with recurrent syn- potassium 2.9 mEq/L, magnesium 1.2 mg/ known as a precipitant of atrial cope and vomiting. Her past medical history dl, calcium 8.8 mg/dl, phosphate 1.9 mg/dl, and supraventricular arrhythmia, the “holi-

Figure 1. 12 lead ECG [A] Sinus rhythm interrupted by episodes of [B] In sinus rhythm, with a severe prolongation of the QT interval polymorphic non-sustained VT B A

439 Case Communications IMAJ • VOL 18 • july 2016

phic VT and prolonged QT should be After correction of electrolytes, with a significant shortening of QT interval [C] treated with intravenous magnesium, as described by Tzivoni et al. [5]. This treat- C ment should be given even if blood chemis- try results are still pending. In summary, alcoholic binge drinking may induce ventricular tachycardia as part of the “holiday heart syndrome.” A combi- nation of hepatic impairment and electro- lyte depletion should raise the suspicion of alcohol abuse. The associated VT should be treated with IV magnesium.

Correspondence Dr. Y. Hellman Head, Service, Dept. of Cardiovascular Medicine, Carmel Medical Center, Haifa 34362, Israel day heart syndrome” (HHS) [1]. This term lapse in general and more specifically of Phone: (972-4) 825-0288 was first used in 1978 in a study that reviewed , as demonstrated in the pres- Fax: (972-4) 825-0936 email: [email protected] patients with arrhythmias following heavy ent case, should be increased. alcohol ingestion [2]. Although the most The combination of abnormal liver References common arrhythmias were supraventricular, function tests with severe electrolyte deple- 1. Tonelo D, Providência R, Gonçalves L. Holiday heart syndrome revisited after 34 years. Arq Bras ventricular arrhythmias occurred as well. tion should raise the possibility of alcohol- Cardiol 2013; 101: 183-9. Later on, additional cases of VT and sudden ism. In fact, the two most common causes 2. Ettinger PO, Wu CF, De La Cruz CJr, Weisse death associated with alcohol consumption of severe hypomagnesemic hypokalemia AB, Ahmed SS, Regan TJ. Arrhythmias and were described [3]. The mechanisms of were alcoholism and cisplatin administra- the “Holiday Heart”: alcohol-associated cardiac rhythm disorders. Am Heart J 1978; 95: 555-62. arrhythmia include conduction disturbance, tion in one report [4]. The use of alcohol 3. Greenspon AJ, Stang JM, Lewis RP, Schaal SF. increased sympathetic activity and metabo- and possibly chronic alcoholism was Provocation of ventricular tachycardia after con- lite toxic effects [1]. Perhaps the mechanism supported in our patient by her jaundice sumption of alcohol. N Engl J Med 1979; 301: 1049- 50. in some cases may be the electrolyte abnor- and laboratory values of cholestasis and 4. Elisaf M, Milionis H, Siamopoulos KC. Hypo- mality and not necessarily a direct effect of hepatitis. The presence of hypokalemia in magnesemic hypokalemia and hypocalcemia: alcohol on the heart. this patient could be explained by diuresis clinical and laboratory characteristics. Miner With growing alcohol consumption induced by alcohol and no intake of food or Electrolyte Metab 1997; 23: 105-12. 5. Tzivoni D, Banai S, Schuger C, Benhorin J, among Israeli youth, awareness of alcohol other potassium-rich substitutes. Treatment of torsade de pointes with magnesium as a potential cause of cardiovascular col- Lastly, repetitive episodes of polymor- sulfate. Circulation 1988; 77: 392-7.

Capsule

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