Cardiac devices with class 1C antiarrhythmics: A potentially toxic combination. Electrophysiological disorders of the heart. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation): Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. the pacemaker or pulse generator) and a lead or leads. Paced, Fusion, and Capture Beats Approach to a Pacemaker ECG A pacemaker consists of a box (i.e. It should be narrower and have a different morphology than your paced beats. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias – executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients with Supraventricular Arrhythmias) Circulation. Capture beats the native beat breaks through and is conducted by the ventricle. Toxicity in these patients may present with pacemaker ventricular capture latency or failure to capture.īlomstrom-Lundqvist C, Scheinman MM, Aliot EM, et al. CONCLUSIONS Flecainide increases the ventricular capture threshold for pacemakers. The flecainide level drawn on arrival was 3.09 mcg/mL. After multiple boluses of IV sodium bicarbonate, the QRS acutely narrowed, latency interval improved, and consistent pacing capture was achieved. 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. 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. Lab work was notable for creatinine at 2.12 mg/dL. She was found to be hypotensive and bradycardic, with a heart rate between 30 to 40 beats per minute. 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. 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. 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. BACKGROUND Flecainide is a class Ic antiarrhythmic agent used in the treatment of supraventricular and ventricular arrhythmias.
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