We report a case of a flecainide-induced cardiogenic shock in a 52-year-old (175 cm, 77 kg) woman with paroxysmal AF. She was previously effectively treated for one year with flecainide (200 mg) as PIP. The medication was well tolerated. Episodes of palpitations every 3-4 weeks disappeared typically after 1-2 hours after taking flecainide. Systolic function was normal in an echocardiography one year before the actual admission. She was otherwise fit and without any other known cardiovascular disease.
She presented one evening to the Emergency Department of a referring hospital with persisting palpitations. The symptoms had started the evening before, and the usual 200 mg flecainide had been ineffective.
Clinical examination showed a fast, irregular heartbeat and was otherwise unremarkable. Blood pressure (BP) was 136/87 mmHg and oxygen saturation (SpO2) is 98% in room air. The electrocardiogram (ECG) showed tachyarrhythmic AF with 158 bpm (Figure 1).
The next day 300 mg flecainide p.o. (the recommended dose for patients with >70 kg) was given, and one hour later, the patient reported malaise and dyspnea, which rapidly worsened and she became tachypneic and severely hypotonic. Echocardiography revealed a severely reduced left ventricular ejection fraction (LVEF) of 30%. The patient was started on i.v. catecholamines and nasal oxygen and was urgently transferred to our center.
Upon arrival, the patient was dyspneic, SpO2 96% with 2 l/min nasal oxygen, responsive and conscious, and BP was 100/48 mmHg under catecholamine support. ECG showed AF (120 bpm). Echocardiography revealed a severely reduced LVEF of only 18%. Chest X-ray showed pleural effusion and increased cardiothoracic ratio (Figure 2(a)).
As electrical cardioversion was unsuccessful, she was started on amiodarone. Bisoprolol was continued at 5 mg/day. Coronary angiography was unremarkable.
Heart rate decreased to around 100 bpm, and over the following 7 hours, catecholamines were fully weaned. Cardiac MRI on the fifth day after admission showed LVEF of 41%, without signs of inflammation or myocardial fibrosis. One day later, she converted into SR. An elective pulmonary vein isolation (PVI) was scheduled, and the patient was discharged with a full cardiovascular recovery (Figure 2(b)). At the time of this report, 4 months after the PVI and 5 months after the admission with cardiogenic shock, the patient negates any symptoms of AF recurrence or heart failure.