With a growing geriatric population, physicians will be seeing more patients on acetylcholinesterase inhibitors, and identifying this as a reversible cause of bradyarrhythmia associated syncope would be essential. 2 Our case describes a patient with symptomatic bradyarrhythmia most likely due to donepezil, who improved after discontinuation of the drug. In a case series among patients on donepezil experiencing syncope, 69% of patients had an identifiable etiology, with sinus node dysfunction being the most common cause. Although rarely reported, acetylcholinesterase inhibitors have the potential to exert vagotonic effects on the SA, resulting in symptomatic bradyarrhythmias. Axis QRS +ve in I, II LAD: Inf MI, WPW, LVH, LBBB, LAFBRAD:AntLat MI, WPW, RVH, RBBB, LPFB, dextrocardia, normal RAD LAD Intervals PR 120-200ms (3-5 small boxes) HiPR: AV block (1,2,3) LoPR: WPW, ectopic atrial pacemaker QRS <100-120ms (<2. The patient has been followed up and has not had any more symptoms or reported problem with his arrhythmia.ĭonepezil is reversible acetylcholinesterase inhibitor that has been approved by the Food and Drug Administration for the treatment of Alzheimer’s disease. The patient was educated about the same, and donepezil was discontinued. Investigating for reversible causes, a possible adverse effect of donepezil, using the Naranjo algorithim, 1 was determined. The patient’s symptoms were explained with his recorded arrhythmia however, the cause was not known. The patient started complaining of some lightheadedness the next morning, and his cardiac recording demonstrated prolonged bradycardia, with a pulse of around 30 beats per minute, followed by a 10-second sinus pause, and then resolving, with atrial fibrillation that lasted a day before converting to normal sinus rhythm. The patient was admitted to the hospital with continuous cardiac monitoring for observation and work-up of his symptoms. His electrocardiogram showed normal sinus rhythm, and his laboratory findings were benign. On examination, the patient was hemodynamically stable, with his physical examination within normal limits. He reported not having such symptoms in the past, and there was no family history of any cardiac disease. He was on lisinopril and metformin and was on donepezil 5 mg, which had been increased to 10 mg 2 weeks earlier. The patient had a past medical history of hypertension, diabetes mellitus, and recently-diagnosed Alzheimer’s dementia. On presentation to the ED, his symptoms had resolved, and he was completely asymptomatic. He described his episodes as having symptoms of lightheadedness and then passing out in a short duration. We report on a 72-year-old man who presented to the emergency department (ED) with two episodes of syncope in the week before his presentation. Drugs that depress sinus node function, including drugs that increase cholinergic tone, have been associated with SSS. Patients may present with symptoms of fatigue, lightheadedness, presyncope, syncope, dyspnea on exertion, angina, and/or palpitations. SSS can also be accompanied by AV nodal conduction disturbances and by paroxysmal supraventricular tachycardia as part of the tachycardia–bradycardia syndrome. This could result in profound sinus bradycardia, sinus pauses, sinus arrest, SA nodal exit block, and inappropriate responses to physiological demands during exercise or stress. Published by IMR press.To the Editor: Sick sinus syndrome (SSS) is characterized by dysfunction of the sinoatrial (SA) node that is often secondary to degeneration of the SA node and surrounding atrial myocardium. We attempt to review the relationship between these two diseases and conclude that appropriate diagnosis of myxedema coma, may be beneficial in reducing the need for pacemaker implantation.Ītrial fibrillation with slow ventricular rate case report hypothyroidism myxedema. Here we report a case of an 83-year-old female who presented with myxedema coma and atrial fibrillation with tachycardia and intermittent slow ventricular response. Tachy-Brady syndrome is considered to be a type of sick sinus syndrome, where the heart alternates between tachycardia and bradycardia, and it is usually treated with pacemaker implantation along with rate slowing medical therapy. Sick sinus syndrome is a group of arrhythmias caused by the malfunction of the natural pacemaker of the heart. Bradycardia is a well-known cardiac manifestation for myxedema coma however, not all bradycardia with hypothyroidism are sinus bradycardia. Myxedema coma occurs mostly in patients with long-standing untreated or undertreated hypothyroidism.
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