Brugada Electrocardiographic Pattern And Cardiovascular Complications Associated With Cocaine Toxicity

M. Chadi Alraies M.D., Abdul Hamid Alraiyes M.D., Samer Alhindi M.D., Richard Christie M.D.
Internal Medicine Residency Program, Department of Internal Medicine
Case Western Reserve University - St. Vincent Charity Hospital – Cleveland, Ohio
The Case Cocaine induced dysrhythmias Treatment of Cocaine Intoxication With Myocardial Complications
• The event: A previously healthy 27-year-old man ingested the content of a bag of cocaine as an impulsive • What is the diagnosis of this electrocardiogram (ECG)? • Which of the following agents considered first line for the management of cocaine induced myocardial
gesture to avoid police detection. One hour later, he developed psychomotor agitation and generalized seizures. 1. Acute ST-elevation myocardial infarction. injury?
Within seconds, patient found pulseless and the electrocardiogram (ECG) monitoring showed ventricular 2. Bundle branch block (BBB) 1. Metoprolol
asystole. CPR started and ventilation with supplemental oxygen by endotracheal (ET) intubation two ampules of 3. Ventricular tachycardia 2. Lisinopril
Epinephrine and two ampules of Sodium Bicarbonate delivered by EMS immediately restored spontaneous heart 4. Accelerated AV junctional rhythm. 3. Lorazepam
beats. 4. Phentolamine
5. Brugada pattern.
5. Tissue plasminogen activator (t-PA)
• Vitals signs: Temperature of 39oC peripheral pulse of 70 bmp, blood pressure 90/70mm Hg, respiratory rate 32, • The electrocardiograms are showing accelerated idioventricular rhythm at 66 beats/min, QRS (0.44 sec), • Cocaine has no known antidote. Lorazepam supportive care and benzodiazepines such as lorazepam is the
SpO2 98% with full ventilator support (FiO2 100%), and Glasgow Coma scale of 5/15. QTc (0.533 sec) with right bundle branch block (RBBB) and left anterior hemiblock (LAHB) configuration, cornerstone of therapy. Furthermore, benzodiazepines considered first line treatment of cocaine related
and rSR' pattern with coved ST-segment elevation in V1 and more clearly in V2 mimicking Brugada myocardial injury. Review the following table for the agents recommended by AHA for treatment.
• Physical exam: Pupils were fixed, dilated and non-reactive to light bilaterally. The fundoscopic exam showed pattern. However, underlying ischemia/infraction can’t be ruled out.
arterial narrowing. His skin was warm and flushed and his oral mucosa was dry with no signs of tongue Cocaine And Sodium Bicarbonate
laceration. Bilateral crackles more on the right than the left side heard on chest examination. Heart exam was • Which of the following cardiac dysrhythmias and conductions disturbances reported with cocaine • Several reports have described the treatment of cocaine-induced wide-complex tachycardia including
significant for regular rate and rhythm with frequent escaped beats. The abdominal exam was negative. use? Brugada pattern, associated with drugs having sodium channel blocking action, such as cocaine with the
1. Bundle-branch block administration of sodium bicarbonate
• Initial work-up: Severe anion-gap metabolic acidosis with elevated lactic acid, creatinine kinase and myocardial 2. Accelerated idioventricular rhythm
Troponin I. 3. Ventricular tachycardia
4. Torsade de pointes
• Electrocardiogram: serial ECG’s done and shown below (ECG 1 and ECG 2) 5. Brugada pattern (right bundle-branch block with ST-segment elevation in leads V1, V2, and V3)
6. All of the above.

• All of the choices in previous question are correct. But the precise arrhythmogenic potential of the drug is
poorly defined. Suggested mechanisms:
• As a sympathomimetic agent, it may increase ventricular irritability and lower the threshold for
fibrillation.
• Inhibits the generation and conduction of the action potential as a result of its sodium-channel-
blocking effects.
• Increases the intracellular calcium concentration
• It reduces vagal activity, which potentiates cocaine’s sympathomimetic effects.

• Which one of the following antiarrhythmics safe in patients with cocaine induced ventricular
tachycardia or fibrillation?
1. Lidocaine
2. Quinidine
3. Procainamide
4. Disopyramide
5. Non of the above
• Lidocaine has been used safely in patients with cocaine induced ventricular tachycardia or fibrillation. Class IA
antiarrhythmic drugs, such as quinidine, procainamide, and disopyramide, should be avoided, since they may
exacerbate prolongation of the QRS and QT intervals and slow the metabolism of cocaine and its metabolites.

Cocaine And Brugada syndrome

ECG 1 on arrival to ER
The syndrome is characterized by (ECG) pattern of right bundle branch block (RBBB) with coved or occasionally
saddleback ST-segment elevation in leads V1 through V3, the absence of demonstrable structural heart disease,
and a propensity for ventricular tachycardia, ventricular fibrillation, and sudden cardiac death.

The arrhythmogenic potential of cocaine is extremely complex and poorly understood. Theses characteristic ECG
changes occasionally are transient and may be exposed by sodium channel blocker, such as cocaine, or
procainamide in patients with “latent” Brugada syndrome.

There is considerable debate in the literature whether an incidental finding of the Brugada pattern on the ECG of
asymptomatic individuals with no family history of sudden death warrants an electrophysiologic evaluation.

Back To The Case

The patient was treated with IV fluids boluses and continuous infusion, sodium bicarbonate and lorazepam (1
mg/h) drips. All this led to hemodynamic stabilization and almost normalization of serum bicarbonate and PH
From: N Eng J Med, Lange RA, cardiovascular Complications of Cocaine. Vol. 345 No. 5
levels. Subsequently, repeated ECG showed normal sinus rhythm. Cardiac catheterization showed normal
coronary arteries with normal LV EF of 60%. Patient discharged back to the jail and to follow up with
electrophysiology clinic.

Cocaine-Induced Myocardial Infarction Conclusion

Cocaine can unmask latent Brugada syndrome in patient with the susceptible gene. Cocaine associated seizures
Three suggested mechanisms: and severe metabolic acidosis is multifactorial. Electrocardiogram has a low sensitivity in detecting cocaine-
ECG 2. six hours after arrival to ED 1. An increased myocardial oxygen demand in the face of a limited or fixed supply. related myocardial ischemia and infarction. Sodium bicarbonate has more than one indication in the management
2. Marked vasoconstriction of the coronary arteries. of cocaine toxicity, reversal of the metabolic acidosis, treatment of rhabdomyolysis, and reversal of the sodium
3. Enhanced platelet aggregation and thrombus formation. channel blocking property of cocaine on myocardium.