Amiodarone causes QT prolongation in patients with atrial fibrillation complicating dyspepsia: a case report
DOI:
https://doi.org/10.18203/2319-2003.ijbcp20261969Keywords:
Amiodarone, Atrial fibrillation, Elderly, Hepatotoxicity, QTc interval prolongationAbstract
A 62-year-old female patient presented to the hospital with complaints of dizziness, weakness, and fever for two days. On admission, her vital signs revealed an increased pulse rate and a temperature above normal. On the first day of hospitalization, her blood pressure rose to 145/94 mmHg before later fluctuating within the normal range. The patient's diagnosis included fatigue and febrile illness, dyspepsia, and AF RVR (Atrial fibrillation with rapid ventricular response). Subsequent laboratory tests showed elevated SGOT, SGPT, and CK-MB values above normal. Tests for HBSAg, anti-JAV, anti-HCV, and swab antigen were negative. During hospitalization, QT interval (QTc) prolongation was detected: the interval was 457 ms (Grade 1) on the second day and 481 ms (Grade 2) on the third day. Treatment began with Amiodarone 100 mg orally every 12 hours for the first two days. Additional medications included Bio Curliv (1 tablet every 8 hours orally), Zypraz (alprazolam) 0.25 mg once daily, tramadol 1 amp in 500 cc NaCl (infused over 8 hours as needed), Sistenol (N-acetylcysteine and paracetamol) 1 tablet every 8 hours orally, Norages (Metamizole) 1 ampoule on the first day, and Esomeprazole 1 tablet once daily. On the third day, Amiodarone was adjusted to 150 mg in 50 cc Dex 50% over 30 minutes, and then changed to 200 mg three times daily until discharge if the patient converted. Throughout treatment, pharmacists played an important role in monitoring for side effects, specifically QTc prolongation and elevated liver enzyme levels (SGOT and SGPT). Therefore, patients with AF require regular ECG monitoring to detect early QTc prolongation.
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References
Saleh K, Haldar S. Atrial fibrillation: a contemporary update. Clin Med. 2023;23(5):437-41. DOI: https://doi.org/10.7861/clinmed.2023-23.5.Cardio2
American Heart Association. Living With Atrial Fibrillation (AFib). American Heart Association. 2024.
Kornej J, Börschel CS, Benjamin EJ, Schnabel RB. Epidemiology of Atrial Fibrillation in the 21st Century: Novel Methods and New Insights. Circulat Res. 2020;127(1):4-20. DOI: https://doi.org/10.1161/CIRCRESAHA.120.316340
Karatela MF, Calkins H. The Global Impact of Atrial Fibrillation. Arrhythm Electrophysiol Rev. 2025;14:e28. DOI: https://doi.org/10.15420/aer.2025.33
Elsheikh S, Hill A, Irving G, Lip GYH, Abdul-Rahim AH. Atrial fibrillation and stroke: State-of-the-art and future directions. Curr Problems Cardiol. 2024;49(1):102181. DOI: https://doi.org/10.1016/j.cpcardiol.2023.102181
Ding Q, Wang Z, Lu L, Song Z, Ge M, Zhou Q. QTc interval prolongation and risk of atrial fibrillation recurrence: a meta-analysis and observational cohort study. Front Cardiovasc Med. 2024;11:1483591. DOI: https://doi.org/10.3389/fcvm.2024.1483591
Ninomiya Y, Enokizono K, Kawasoe S, Kubozono T, Kamada H, Iriki Y, et al. QT prolongation and excessive variability predicts new-onset atrial fibrillation in the health screening data of Japanese adults. Sethi Y, editor. PLoS One. 2025;20(10):e0333169. DOI: https://doi.org/10.1371/journal.pone.0333169
Chelikam N, Kambhampati S, Katapadi A, Lakkireddy D. Dofetilide unmasks long QT in a patient presenting with atrial fibrillation–induced cardiomyopathy. HeartRhythm Case Rep. 2024;10(10):717-20. DOI: https://doi.org/10.1016/j.hrcr.2024.07.006
Darbar D, Kimbrough J, Jawaid A, McCray R, Ritchie MD, Roden DM. Persistent Atrial Fibrillation Is Associated with Reduced Risk of Torsades de Pointes in Patients with Drug-Induced Long QT Syndrome. J Am College Cardiol. 2008;51(8):836-42. DOI: https://doi.org/10.1016/j.jacc.2007.09.066
Stojanovic M, Nikolic M, Nedeljkovic I, Gojkovic D. QT Prolongation Preceding Ventricular Fibrillation After Amiodarone Administration: A Case Report. Cureus. 2024;16(7):e63763. DOI: https://doi.org/10.7759/cureus.63763
Curigliano G. QTc prolongation assessment in anticancer drug development: Clinical and methodological issues. eCancer. 2009;3:130. DOI: https://doi.org/10.3332/ecancer.2008.130
Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Europ Heart J. 2021;42(5):373-498. DOI: https://doi.org/10.1093/eurheartj/ehaa798
Nordkin I, Levinas T, Rosenfeld I, Halabi M. Torsades de pointes after prolonged intravenous amiodarone therapy for atrial fibrillation. Clin Case Rep. 2021;9(1):391-4. DOI: https://doi.org/10.1002/ccr3.3539
Nafrialdi, Kurniawan TG, Setiawati A, Makmun LH. QT Interval Prolongation Associated with Amiodarone Use in Cipto Mangunkusumo Hospital, Jakarta. Acta Medica Indonesiana. 2014;46(4):292-7.
Platonov PG, McNitt S, Polonsky B, Rosero SZ, Zareba W. Atrial Fibrillation in Long QT Syndrome by Genotype. Circ: Arrhythmia Electrophysiol. 2019;12(10):e007213. DOI: https://doi.org/10.1161/CIRCEP.119.007213
Campinas A, Pereira Santos M, Sousa MJ, Gomes C, Torres S. Amiodarone-Induced Electrical Storm: A Nightmare in the Emergency Room. Cureus. 2023;15(11):e49494.. DOI: https://doi.org/10.7759/cureus.49494
Ismagilov AD, Shikh EV, Sizova ZM, Shindryaeva NN. Prolongation of the QT interval in patients with coronary heart disease as consequence of drug-drug interactions on metabolic rate. Electron J Gen Med. 2018;15(4):em68. DOI: https://doi.org/10.29333/ejgm/93166
Hubel E, Fishman S, Holopainen M, Käkelä R, Shaffer O, Houri I, et al. Repetitive amiodarone administration causes liver damage via adipose tissue ER stress-dependent lipolysis, leading to hepatotoxic free fatty acid accumulation. Am J Physiol Gastroint Liver Physiol. 2021;321(3):G298-307. DOI: https://doi.org/10.1152/ajpgi.00458.2020
Cimic A, Sirintrapun J. Amiodarone Hepatotoxicity with Absent Phospholipidosis and Steatosis: A Case Report and Review of Amiodarone Toxicity in Various Organs. Case Rep Pathol. 2013;2013:1-4. DOI: https://doi.org/10.1155/2013/201095
Calderon-Martinez E, Landazuri-Navas S, Kaya G, Cinicola J. Chronic Oral Amiodarone as a Cause of Acute Liver Failure. J Med Cases. 2023;14(2):59-63. DOI: https://doi.org/10.14740/jmc4044
Buggey J, Kappus M, Lagoo AS, Brady CW. Amiodarone-Induced Liver Injury and Cirrhosis. ACG Case Rep J. 2015;2(1):116-8. DOI: https://doi.org/10.14309/crj.2015.23
Nagata T, Takata K, Shakado S, Hirai F. Amiodarone-induced hepatotoxicity. BMJ Case Rep. 2023;16(11):e256679. DOI: https://doi.org/10.1136/bcr-2023-256679
Bauerlein DK, Akbar HN, von Rosenvinge EC, Loughry ND, John PR. Benefit of N-Acetylcysteine in Postoperative Hepatic Dysfunction: Case Report and Review of Literature. Case Rep Hepatol. 2019;2019:1-4. DOI: https://doi.org/10.1155/2019/4730381
Pulley JM. Acetylcysteine (N-acetylcysteine, NAC) for the management of non-acetaminophen-induced acute liver failure. Vanderbilt Institute for Clinical and Translational Research. 2020.
Licata A, Minissale MG, Stankevičiūtė S, Sanabria-Cabrera J, Lucena MI, Andrade RJ, et al. N-Acetylcysteine for Preventing Acetaminophen-Induced Liver Injury: A Comprehensive Review. Front Pharmacol. 2022;13:828565. DOI: https://doi.org/10.3389/fphar.2022.828565
Verma A, Mallick P, Dwivedi P, Singh A. Exogenous supplementation of N-acetylcysteine can reduce hepatotoxicity induced by ascites fluid (cell-free) adsorbed over Protein-A-containing Staphylococcus aureus Cowan-I without compromising its antitumor effect†. J Pharm Bioall Sci. 2019;11(3):205. DOI: https://doi.org/10.4103/jpbs.JPBS_216_18
Kaya S, Yalcın T, Tektemur A, Kuloğlu T. N-Acetylcysteine may exert hepatoprotective effect by regulating Meteorin-Like levels in Adriamycin-induced liver injury. Cell Stress Chaperones. 2023;28(6):849-59. DOI: https://doi.org/10.1007/s12192-023-01376-3
Farzaei M, Zobeiri M, Parvizi F, El-Senduny F, Marmouzi I, Coy-Barrera E, et al. Curcumin in Liver Diseases: A Systematic Review of the Cellular Mechanisms of Oxidative Stress and Clinical Perspective. Nutrients. 2018;10(7):855. DOI: https://doi.org/10.3390/nu10070855
Miljković M, Rančić N, Simić R, Stamenković D, Dragojević-Simić V. Metamizole: Current status of the safety and efficacy. Hosp Pharm Int Multi J. 2018;5(3):694-704. DOI: https://doi.org/10.5937/hpimj1803694M
Stromer W, Fontanilla P, Cywińska-Durczak B. Safety of metamizole superior to comparable OTC analgesics. Evidence Self-Medicat. 2025;5:1-4.
Kötter T, da Costa BR, Fässler M, Blozik E, Linde K, Jüni P, et al. Metamizole-Associated Adverse Events: A Systematic Review and Meta-Analysis. Manzoli L, editor. PLoS ONE. 2015;10(4):e0122918. DOI: https://doi.org/10.1371/journal.pone.0122918
Puspitasari AD, Azizah AN, Nilamsari WP, Nurhariansyah R, Palupi IN. Utilisation study of antipyretic drugs in paediatric patients. Pharm Educ. 2024;24(3):234-9. DOI: https://doi.org/10.46542/pe.2024.243.234239
Hachimi-Idrissi S, Coffey F, Dobias V, Hautz W, Leach R, Sforzi I. Guidelines for the management of acute pain in emergency situations. The European Society for Emergency Medicine (EUSEM), Aartselaar Belgium. 2020. DOI: https://doi.org/10.1007/s11739-020-02477-y
Wertli MM, Flury JS, Streit S, Limacher A, Schuler V, Ferrante AN, et al. Efficacy of metamizole versus ibuprofen and a short educational intervention versus standard care in acute and subacute low back pain: a study protocol of a randomised, multicentre, factorial trial (EMISI trial). BMJ Open. 2021;11(10):e048531. DOI: https://doi.org/10.1136/bmjopen-2020-048531
Subedi M, Bajaj S, Kumar MS, Yc M. An overview of tramadol and its usage in pain management and future perspective. Biomed Pharmacoth. 2019;111:443-51. DOI: https://doi.org/10.1016/j.biopha.2018.12.085
O’Connor J, Christie R, Harris E, Penning J, McVicar J. Tramadol and Tapentadol: Clinical and Pharmacologic Review. World Federation Societies Anaesthesiologists. 2019;1-6.
Khan TB, Singh A, Rani D. Tramadol use for chronic pain management: A thorough analysis of safety, effectiveness, and clinical recommendations. GJHSR. 2024;3:11-4. DOI: https://doi.org/10.25259/GJHSR_30_2024
Blondell RD, Azadfard M, Wisniewski AM. Pharmacologic Therapy for Acute Pain. Am Family Phys. 2013;87(11):7.
Inage K, Sainoh T, Okuyama K, Yamashita M, Ohyama S, Fujimoto K, et al. The Analgesic and Side Effects of Tramadol Hydrochloride Immediate-Release and Extended-Release Tablets in Patients with Chronic Low Back Pain. Cureus. 2024;16(10):1-6. DOI: https://doi.org/10.7759/cureus.72124
Harer KN, Hasler WL. Functional Dyspepsia: A Review of the Symptoms, Evaluation, and Treatment Options. Gastroenterol Hepatol. 2020;16(2):9.
Wang WH, Huang JQ, Zheng GF, Xia HHX, Wong WM, Liu XG, et al. Effects of Proton-Pump Inhibitors on Functional Dyspepsia: A Meta-analysis of Randomized Placebo-Controlled Trials. Clin Gastroenterol Hepatol. 2007;5(2):178-85. DOI: https://doi.org/10.1016/j.cgh.2006.09.012
Mössner J. The Indications, Applications, and Risks of Proton Pump Inhibitors. Dtsch Aerztebl Online. 2016;113(27-28):477-83. DOI: https://doi.org/10.3238/arztebl.2016.0477
van Zanten SV, Armstrong D, Chiba N, Flook N, White RJ, Chakraborty B, et al. Esomeprazole 40 mg Once a Day in Patients with Functional Dyspepsia: The Randomized, Placebo-Controlled “ENTER” Trial. Am J Gastroenterol. 2006;101(9):2096-106. DOI: https://doi.org/10.1111/j.1572-0241.2006.00751.x
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