e-Herz: Case study Herz 2013 · 38:556–557 DOI 10.1007/s00059-012-3725-7 Received: 18 September 2012 Revised: 20 October 2012 Accepted: 21 October 2012 Published online: 23 January 2013 © Urban & Vogel 2013
e-Herz
A 60-year-old male patient presented to our emergency room complaining of dizziness and syncope. His medical history included mitral valve replacement 5 years previously, atrial fibrillation for 4 years, and glaucoma for 10 days. Medication consisted of warfarin (5 mg/day; for 5 years) and latanoprost/timolol 50 mcg/ ml+5 mg/ml eye drops (Xalacom®, Pfizer, Belgium) once for each eye for 10 days. He had no history of taking digoxin or other atrioventricular node-blocking agents and herbal agents. Examination revealed a blood pressure of 85/50 mmHg, a pulse of 30 bpm, and a metallic heart sound at the apex; the other systemic findings were un-
Fig. 1 7 Electrocardiogram showing atrial fibrillation with low ventricular rate (35 bpm) on admission to the emergency room
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U. Canpolat · K.M. Gürses · K. Aytemir · A. Oto Faculty of Medicine, Department of Cardiology, Hacettepe University, Sihhiye, Ankara
Severe bradycardia and syncope due to topical ophthalmic timolol remarkable. Electrocardiography on admission demonstrated atrial fibrillation with a low atrial rate (35 bpm) (. Fig. 1). Previous ECG records at regular checkup visits revealed atrial fibrillation with a normal ventricular rate approximately between 85 and 95 bpm. The patient’s latest ECG had been recorded was 1 month earlier (. Fig. 2) Echocardiography showed normal left ventricular systolic function, a normal mitral prosthetic valve, and a dilated left atrium (61 mm). Because of the hemodynamic instability of the patient, temporary transvenous pacemaker implantation was performed through the jugular venous approach and ECG re-
vealed a ventricular pacemaker rhythm of 60 bpm (. Fig. 3). Afterwards, the patient’s hemodynamics improved and he was asymptomatic. Use of the ophthalmic solution timolol was discontinued. He was hospitalized for 5 days to observe the underlying rhythm. There was persistence of atrial fibrillation with a low ventricular response during the hospital stay. Therefore, permanent pacemaker implantation (VVI) was performed successfully with no complications. The remaining hospital stay was uneventful. The patient was asymptomatic at the 1-month and 6-month follow-up visits, and a checkup of the pacemaker revealed 89% right
Fig. 2 9 Previous ECG at a check-up visit (1 month earlier) showed atrial fibrillation with a ventricular rate of 90 bpm
Fig. 3 9 ECG showing the pacemaker rhythm (60 bpm)
ventricular pacing with a baseline rate of 60 bpm. Timolol maleate is a nonselective β-adrenoceptor antagonist currently used mainly as an ocular preparation for the treatment of glaucoma and ocular hypertension. Despite the topical administration, ophthalmic timolol causes systemic adrenergic β-blocking because of absorption from the eye into the systemic circulation [1]. It can cause atrioventricular block and bradycardia. Although most of the cardiovascular complications such as bradyarrhythmia and atrioventricular blocks are reversible, there may be permanent bradycardia and requirement for pacemaker implantation [2, 3]. Because the pharmacokinetics of ophthalmic timolol is dependent on the CYP2D6 genotype, poor metabolizers of CYP2D6 may be more prone to bradycardia
than extensive metabolizers [1]. Our patient had atrial fibrillation, and ventricular rate control was achieved without a further atrioventricular nodal blocking agent. After taking timolol, he became bradyarrhythmic and subsequently had syncope. Therefore, it is important to ask about the use of eye-drops with β-blockers in patients with complaints of presyncope or syncope and findings of bradycardia or atrioventricular block.
Corresponding address U. Canpolat Faculty of Medicine, Department of Cardiology, Hacettepe University 06100 Sihhiye, Ankara Turkey
[email protected]
Conflict of interest. On behalf of all authors, the corresponding author states that there are no conflicts of interest.
References 1. Nieminen T, Lehtimaki T, Maenpaa J et al (2007) Ophthalmic timolol: plasma concentration and systemic cardiopulmonary effects. Scan J Clin Lab Invest 67:237–245 2. Rubin Lopez JM, Hevia Nava S, Veganzones Bayon A, Barriales Alvarez V (1999) Atrioventricular block secondary to topical ophthalmic beta blockers. Rev Esp Cardiol 52:532 3. Chun JG, Brodsky MA, Allen BJ (1994) Syncope, bradycardia, and atrioventricular block associated with topical ophthalmic levobunolol. Am Heart J 127:689–690
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