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Drug Induced Arrhythmias – AHA Statement

Written by Clay Smith

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Be aware that many medications can induce cardiac arrhythmias. Here are the usual suspects.

Why does this matter?
Most of us are aware that several drugs and drug classes may prolong the QT interval and predispose a patient to torsades de pointes. But did you know multiple medications are also associated with atrial fibrillation, atrial tachycardia, bradyarrhythmias, atrioventricular nodal reentrant tachycardia (AVNRT), monomorphic ventricular tachycardia (VT), and unmasking Brugada syndrome?

Careful with that Rx pad…
For each arrhythmia, there are numerous drugs that may cause it. I can’t list them all. It is important for you to pull the full text of this article and read through it for yourself. But I will try to list the most commonly encountered meds in the ED for each drug-induced rhythm disturbance.

Bradyarrhythmias

  • Propofol

  • Physostigmine

  • Adenosine, amiodarone, sotalol

  • Citalopram, fluoxetine

  • Clonidine, beta blockers, verapamil, diltiazem

  • Digoxin

  • Dipyridamole

Atrial fibrillation/flutter; a similar list causes atrial tachycardia as well

  • Adenosine, amiodarone

  • Multiple antineoplastic agents: tyrosine kinase inhibitors, anthracyclines, alkylating agents, HER2 receptor blockers, 5FU, microtubule agents

  • Fluoxetine

  • Ondansetron

  • Diclofenac, COX2 inhibitors, corticosteroids

  • Prochlorperazine, olanzapine

  • Bisphophonates

  • Albuterol, terbutaline

  • Cannabis

  • Dobutamine, dopamine, epinephrine

  • Alcohol

  • Physostigmine

  • Amphetamines

  • Milrinone

  • Morphine

  • Sildenafil

  • Caffeine (say it isn’t so…)

  • Isoproterenol

AVNRT

  • Phenylpropanolamine

  • Clozapine, fluoxetine

  • Albuterol

  • Dobutamine

  • Methylprednisolone

  • Furosemide

  • Caffeine (that explains a lot…), methylphenidate

Monomorphic VT

  • Bupivacaine

  • Adenosine, amiodarone, propafenone, procainamide

  • 5FU, anthracyclines, immune checkpoint inhibitors (myocarditis)

  • Bupropion, citalopram, imipramine, venlafaxine, trazodone, lithium

  • Dipyridamole

  • Chlopromazine

  • Digoxin, dobutamine

  • Terbutaline

  • Methamphetamine

Brugada

  • Flecainide, propafenone, procainamide

  • Tricyclics

  • Bupivacaine, propofol

  • Alcohol, lithium, oxcarbazepine

Torsades de pointes (via prolonged QT interval)

  • Propofol

  • Amiodarone, flecainide, ibutilide, procainamide

  • Azithromycin, ciprofloxacin, levofloxacin

  • Citalopram

  • Droperidol (although you may want to read this…), ondansetron

  • Fluconazole, pentamidine

  • Hydroxychloroquine

  • Haloperidol

  • Methadone

Again, this is not an exhaustive list. It’s probably best for you to review the full article. I listed the ones you will encounter most often in clinical practice and in the ED. You will see some recurrent offenders on several of these lists. Be especially wary of these agents. Not only should you be careful what you prescribe and to whom; be sure to also think in reverse – if a patient presents with an arrhythmia, check the med list.

Source
Drug-Induced Arrhythmias: A Scientific Statement From the American Heart Association. Circulation. 2020 Sep 15:CIR0000000000000905. doi: 10.1161/CIR.0000000000000905. Online ahead of print.

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