To our knowledge, this is the first Asian case of a quetiapine-induced junctional rhythm. We did not rechallenge with quetiapine to prove its effects because of the documented cardiovascular side effects of quetiapine.įigure 1: A standard 12-lead electrocardiogram showing junctional rhythmįigure 2: A standard 12-lead electrocardiogram showing junctional rhythmįigure 3: A standard 12-lead electrocardiogram showing normal sinus rhythm with inverted T waves in the precordial leads He was discharged with stable mental and cardiac conditions. The follow-up serum cardiac enzymes were all within normal limits, and the ECG continued to reveal junctional rhythm until 4 days after the event when it returned to normal sinus rhythm. Examination revealed a regular, slow pulse rate (50 bpm), and low blood pressure (90/60 mmHg) without orthostasis. The newly-added medication was highly suspected as being the cause of this condition, and consequently, quetiapine was immediately stopped from the same day. Serial ECGs were obtained on a daily basis and. Serum chemistries and cardiac enzymes, including creatinine kinase, creatinine kinase-muscle/brain, and troponin-T were all within normal limits. The electrocardiogram (ECG) recording revealed junctional bradycardia. A routine examination by the treating physician revealed bradycardia and was therefore referred to us. ,, The aim of this report is to highlight the cardiac effects of newer neurolepts and to discuss the mechanism therein.Ī 65-year-old male patient with the bipolar affective disorder was initiated on quetiapine for manic episodes. Quetiapine can cause QT interval prolongation and cardiac arrhythmias. Due to co-existing comorbidities (diabetes, hypertension, and cardiac disease), the elderly population is particularly prone to these effects. The sudden onset of cardiac abnormality is particularly considered a life-threatening side effect. Quetiapine is currently the most commonly used second-generation antipsychotic for the treatment of dementia and psychological symptoms in the elderly. Quetiapine induced reversible junctional rhythm. How to cite this URL: Kulkarni SK, Bhiarappa S. How to cite this article: Kulkarni SK, Bhiarappa S. Keywords: Junctional rhythm, quetiapine, second-generation antipsychotic We report a case of a 65-year-old male who experienced junctional rhythm during the treatment of his acute manic episode with quetiapine and returned to normal sinus rhythm after discontinuing the medication. However, several case reports have revealed the arrhythmogenic effect of these drugs as well as orthostatic hypotension, especially in those receiving cardiac medications. These drugs have gained popularity owing to their fewer side-effect profiles. Selective serotonin receptor inhibitor antidepressants and new antipsychotics were introduced to overcome the toxicity of older generation drugs. These drugs inhibit the cardiac Na +, Ca 2+, and K + channels often leading to life-threatening arrhythmia. The T wave is peaked with a narrow base in lead II (Figure 2 - green stars).The cardiovascular side effects of older antidepressants and neurolepts are well known. There is no blocked P wave therefore, answer C, sinus bradycardia with second-degree AV block type II is incorrect. There is no P wave before the second, fourth, and sixth beats therefore, answer B, sinus bradycardia with atrial bigeminy, is incorrect. Therefore, answer A, atrial fibrillation, is not the correct answer. This pattern is repeated periodically, which creates an irregularly regular rhythm. The fourth beat is another junctional beat with same coupling interval from sinus beat (Figure 2 - blue double-sided arrow). The interval between the first and third sinus beats is 2760 ms corresponding to severe sinus bradycardia with a heart rate of 22 bpm (Figure 2 - black double-sided arrow). The third beat is another sinus beat with the same characteristics of the first beat. The second beat is a junctional escape beat with an interval length of 1860 ms corresponding to a heart rate of 32 bpm. The first beat of the rhythm strip is sinus beat with a significant reduction of P wave amplitude (Figure 2 - black arrow) as well as prolongation of the PR interval to 300 ms (Figure 2 - red double-sided arrow). Sinus bradycardia with junctional escape beats.
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