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A Rare Case of Second Degree Mobitz Type II AV Block Associated with Cocaine Use

Pramod Theetha Kariyanna, Apoorva Jayarangaiah, Mohammed Al-Sadawi, Rodaina Ahmed, Jason Green, Iya Dubson, Samy I. McFarlane
American Journal of Medical Case Reports. 2018, 6(7), 146-148. DOI: 10.12691/ajmcr-6-7-7
Received July 08, 2018; Revised August 12, 2018; Accepted August 21, 2018

Abstract

Cocaine is a commonly abused illicit drug in the United States. The complex effects of cocaine on the conduction system of the human heart has not been completely understood. Cocaine acts as a sympathomimetic by inhibition of reuptake of neuronal catecholamines, leading mostly to tachyarrhythmias on presentation. However, cocaine also exerts other effects on the conduction system including sympathomimetic, sino-bradycardic as well as local anesthetic properties. While Multiple cases of atrioventricular (AV) conduction blocks including first degree AV block, Mobitz type I and third degree AV blocks have been previously reported, we hereby present the first case report of cocaine- induced Mobitz type II second degree AV block. This case occurred in a 55 year old woman who presented with retrosternal chest pressure and tested positive for cocaine abuse as documented by urine toxicology test. Patient spontaneously converted to normal sinus rhythm the following day post admission to the hospital. Cocaine is known to inhibit sodium channels and thus has been known to decrease SA node automaticity and conduction via AV node. Electrophysiology studies have previously confirmed cocaine mediated delay in impulse conduction and repolarization. Though rare, physicians should be aware of the possibility of bradyarrhythmias associated with cocaine abuse in order to apply standard therapy such as pacemaker in the event of non-resolution of this serious arrhythmia.

1. Introduction

Cocaine is a widely used drug of abuse 1. Multiple cardiovascular complications such as myocardial infarction and arterial dissection have been reported with cocaine abuse 2, 3, 4. Net effect of cocaine use is related to its sympathomimetic property, sino-bradycardic effect and local anesthetic property 2, 5, 6. Rare isolated case reports of AV conduction blocks associated with cocaine use have been reported. To the best of our knowledge, we hereby present the first case of Mobitz type II second degree AV block associated with cocaine use.

2. Case Presentation

A 55 year old female with a past medical history of asthma, schizoaffective disorder, presented with a chief complaint of retrosternal chest pain after cocaine use. The patient described the pain as 6/10 in intensity, non-radiating, not related to breathing or changes in position. Pain was no reproducible on chest palpation. The last cocaine use was 10 hours ago. On presentation patient was afebrile, bradycardic at 54 beats per minute, respiratory rate was 16 per minute and blood pressure was 123/58 mm of Hg. Physical examination was benign. The patient was not on any AV nodal blocking agents. Investigations including complete blood count, comprehensive metabolic panel, urine toxicology, thyroid function tests, troponin, brain natriuretic peptide, chest X-ray (CXR) and electrocardiograph (EKG) were obtained. EKG revealed mobitz type II heart block (Image 1). Urine toxicology was positive for cocaine. Thyroid function tests were within normal limits. Troponin levels were also within normal limit. CXR was without any acute abnormalities. Acute coronary syndrome was ruled out. Transthoracic echocardiogram showed normal ejection fraction with no wall motion abnormalities. An outpatient stress test was planned. Cardiac monitoring subsequently revealed normal sinus rhythm on the second day of hospitalization.

3. Discussion

About 1.5 million people reported cocaine use in the past month in 2014. Adolescents in the age group of 18 to 25 years of age reported a prevalence of use of 1.4% 1. Myocardial infarction, arrhythmias, aortic dissection and cardiomyopathy are among the cardiovascular complications reported with cocaine use 2, 3, 4. Cocaine is a neuronal norepinephrine and dopamine reuptake inhibitor and thus acts as a sympathomimetic agent 2. Net effect of cocaine abuse is dependent on sympathomimetic action 2, sino-bradycardic effect 5 and its direct anesthetic properties 6. Multiple studies have reported increase in mean heart rate in cocaine users 7, 8, 9. Studies have reported bradyarrhythmia in patients who presented with chest pain after acute cocaine use 10. A study on asymptomatic chronic cocaine users reported sinus bradycardia in 21% of the cases 11. First degree AV block 12, 13, 14, 15, 16, mobitz type I second degree AV block 17, 18, and third degree AV block 19, 20, 21 has been reported with cocaine use.Cocaine in healthy hearts has been shown to reduce the ventricular effective refractory period however with no change in the intraventricular conduction or spontaneous or induced ventricular arrhythmias 22. Cocaine is also known to cause increase in intra-atrial conduction time, atrioventricular conduction time and atrial effective refractory period 23. Electrophysiology studies have demonstrated cocaine induced prolongation of atrium to the His bundle (AH) as well as His bundle to ventricular (HV) duration 24. Decrease in sinus node automaticity and AV nodal blockade has been reported with cocaine use 25. Despite the experimental evidence that cocaine causes AH and HV conduction delays, limited cases have reported these findings 12, 13, 14, 15, 16, 17, 18, 19, 20, 21. Marked increase effective refractory period in cocaine users is either due to premature stimulation or minimum pacing intervals 25.

The mechanism of cocaine induced conduction abnormality is not entirely understood. Literature review reveals contradictory results of the effect of cocaine on AV conduction as measure by PR interval. Studies have reported cocaine related increase 26, decrease 27 and no effect 28, 29 on PR interval have been reported. Cocaine, when inhaled can cause activation of parasympathetic fibers via nasal vagal neuronal terminals 19, however this mechanism may not provide an explanation to AH and HV conduction delay when cocaine is abused via intravenous routes. The conduction abnormalities associated with cocaine are largely explained by the inhibitory action of cocaine on cardiac sodium channels (INa). Cocaine acts similar to Class I antiarrhythmic drugs which act by inhibiting INa channels. Such inhibition results in prolongation of HV interval and thus QRS duration 24, 25. The increase in action potential duration and thus QT prolongation is secondary to cocaine mediated inhibition of potassium channels (IKr). Depressed repolarization secondary to inhibition of IKr has been noted in SA node and right atrium 25. Bradycardia associated with Mobitz type II in our patient may be explained by delayed HV conduction secondary to inhibition of INa channels.

4. Conclusion

Although Cocaine abuse is often associated with tachyarrhythmias, accumulating evidence through multiple case reports indicate that bradyarrhythmias due to cocaine use is not infrequent. Our case report underscores the possibility of AV conduction blocks associated with cocaine use that is likely due to the net effect of cocaine on conduction system of the heart that include sympathomimetic action and inhibitory action on INa and IKr currents.

Acknowledgements

This work is supported, in part, by the efforts of Dr. Moro O. Salifu M.D., M.P.H., M.B.A., M.A.C.P., Professor and Chairman of Medicine through NIH Grant number S21MD012474.

References

[1]  Center for Behavioral Health Statistics and Quality (CBHSQ). Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015. HHS Publication No. SMA 15-4927, NSDUH Series H-50.
In article      
 
[2]  Afonso, L.; Mohammad, T.; Thatai, D. Crack whips the heart: a review of the cardiovascular toxicity of cocaine. Am. J. Cardiol., 2007, 100(6), 1040-1043.
In article      View Article  PubMed
 
[3]  Maraj, S.; Figueredo, V.M.; Lynn Morris, D. Cocaine and the heart. Clin. Cardiol., 2010, 33(5), 264-269.
In article      View Article  PubMed
 
[4]  Vasica, G.; Tennant, C.C. Cocaine use and cardiovascular complications. Med. J. Aust., 2002, 177(5), 260-262.
In article      PubMed
 
[5]  Jacobsen TN, Grayburn PA, Snyder RW, Hansen J, Chavoshan B, Landau C, Lange RA, Hillis LD, Victor RG. Effects of intranasal cocaine on sympathetic nerve discharge in humans. The Journal of clinical investigation. 1997 Feb 15; 99(4):628-34.
In article      View Article  PubMed
 
[6]  Seelig MG. History of cocaine as a local anesthetic. Journal of the American Medical Association. 1941 Oct 11; 117(15):1284.
In article      View Article
 
[7]  Magnano AR, Talathoti NB, Hallur R et al. Effect of acute cocaine administration on the QTc interval of habitual users. Am. J. Cardiol. 97, 1244-1246 (2006).
In article      View Article  PubMed
 
[8]  Javaid JI, Fischman MW, Schuster CR et al. Cocaine plasma concentration: relation to physiological and subjective effects in humans. Science 202, 227-228 (1978).
In article      View Article  PubMed
 
[9]  Orr D, Jones I. Anaesthesia for laryngoscopy. a comparison of the cardiovascular effects of cocaine and lignocaine. Anaesthesia 23, 194-202 (1968).
In article      View Article  PubMed
 
[10]  Hollander JE, Hoffman RS, Gennis P et al. Prospective multicenter evaluation of cocaine-associated chest pain. Cocaine Associated Chest Pain (COCHPA) Study Group. Acad. Emerg. Med. 1, 330-339 (1994).
In article      View Article
 
[11]  Chakko S, Fernandez A, Mellman TA et al. Cardiac manifestations of cocaine abuse: a cross-sectional study of asymptomatic men chronically abusing ‘crack’ cocaine. J. Am. Coll. Cardiol. 20, 1168-1174 (1992).
In article      View Article
 
[12]  Kalimullah EA, Bryant SM. Case files of the medical toxicology fellowship at the toxikon consortium in Chicago: cocaine-associated wide-complex dysrhythmias and cardiac arrest-treatment nuances and controversies. Journal of Medical Toxicology. 2008 Dec 1; 4(4): 277-83.
In article      View Article  PubMed
 
[13]  Weiner RB, Weiner SD, Yurchak PM. Removing the mask. The American journal of medicine. 2008 Feb 1; 121(2): 113-6.
In article      View Article  PubMed
 
[14]  Bertos-Polo J, Guti C. Aborted sudden death, transient Brugada pattern, and wide QRS dysrrhythmias after massive cocaine ingestion. Journal of electrocardiology. 2001 Oct 1; 34(4): 345-9.
In article      View Article  PubMed
 
[15]  Kerns II W, Garvey L, Owens J. Cocaine-induced wide complex dysrhythmia. The Journal of emergency medicine. 1997 May 1; 15(3): 321-9.
In article      View Article
 
[16]  Grigorov V, Goldberg L, Foccard JP. Cardiovascular complications of acute cocaine poisoning: a clinical case report: case report. Cardiovascular Journal of South Africa. 2004 May 1; 15(3): 139-42.
In article      PubMed
 
[17]  Om A, Ellenbogen KA, Vetrovec GW. Cocaine-induced bradyarrhythmias. American heart journal. 1992 Jul 1; 124(1): 232-4.
In article      View Article
 
[18]  Aryana A, Mooss AN. ST elevation alternans in presence of profound myocardial ischemia and injury induced by cocaine toxicity. Clinical Cardiology: An International Indexed and Peer-Reviewed Journal for Advances in the Treatment of Cardiovascular Disease. 2009 Jul; 32(7):E43-4.
In article      View Article  PubMed
 
[19]  Tanen DA, Greame KA, Curry SC, Curry S. Crack cocaine ingestion with prolonged toxicity requiring electrical pacing. Journal of Toxicology: Clinical Toxicology. 2000 Jan 1; 38(6): 653-7.
In article      View Article  PubMed
 
[20]  Isner JM, Estes III NM, Thompson PD, Costanzo-Nordin MR, Subramanian R, Miller G, Katsas G, Sweeney K, Sturner WQ. Acute cardiac events temporally related to cocaine abuse. New England Journal of Medicine. 1986 Dec 4; 315(23): 1438-43.
In article      View Article  PubMed
 
[21]  Stenberg RG, Winniford MD, Hillis LD, Dowling GP, Buja LM. Simultaneous acute thrombosis of two major coronary arteries following intravenous cocaine use. Archives of pathology & laboratory medicine. 1989 May; 113(5): 521-4.
In article      PubMed
 
[22]  Schwartz AB, Janzen D, Jones RT. Electrophysiologic effects of cocaine on the canine ventricle. Journal of cardiovascular pharmacology. 1989 Feb; 13(2): 253-7.
In article      View Article  PubMed
 
[23]  Temesy-Armos PN, Fraker JT, Brewster PS, Wilkerson RD. The effects of cocaine on cardiac electrophysiology in conscious, unsedated dogs. Journal of cardiovascular pharmacology. 1992 Jun; 19(6): 883-91.
In article      View Article  PubMed
 
[24]  Tracy CM, Bachenheimer L, Solomon A, Cohen MM, Kuhn FE, Jain R, Corr PB, Gillis RA. Evidence that cocaine slows cardiac conduction by an action on both AV nodal and His-Purkinje tissue in the dog. Journal of electrocardiology. 1991 Jul 1; 24(3): 257-62.
In article      View Article
 
[25]  Przywara DA, Dambach GE. Direct actions of cocaine on cardiac cellular electrical activity. Circulation research. 1989 Jul 1; 65(1): 185-92.
In article      View Article  PubMed
 
[26]  Magnano AR, Talathoti NB, Hallur R, Jurus DT, Dizon J, Holleran S, Bloomfield DM, Collins E, Garan H. Effect of acute cocaine administration on the QTc interval of habitual users. American Journal of Cardiology. 2006 Apr 15; 97(8): 1244-6.
In article      View Article  PubMed
 
[27]  Kajdasz DK, Moore JW, Donepudi H, Cochrane CE, Malcolm RJ. Cardiac and mood-related changes during short-term abstinence from crack cocaine: the identification of possible withdrawal phenomena. The American journal of drug and alcohol abuse. 1999 Jan 1; 25(4): 629-37.
In article      View Article  PubMed
 
[28]  Hollander JE, Lozano M, Fairweather P, Goldstein E, Gennis P, Brogan GX, Cooling D, Thode HC, Gallagher EJ. “Abnormal” electrocardiograms in patients with cocaine-associated chest pain are due to “normal” variants. The Journal of emergency medicine. 1994 Mar 1; 12(2): 199-205.
In article      View Article
 
[29]  Levin KH, Copersino ML, Epstein D, Boyd SJ, Gorelick DA. Longitudinal ECG changes in cocaine users during extended abstinence. Drug & Alcohol Dependence. 2008 May 1; 95(1): 160-3.
In article      View Article  PubMed
 

Published with license by Science and Education Publishing, Copyright © 2018 Pramod Theetha Kariyanna, Apoorva Jayarangaiah, Mohammed Al-Sadawi, Rodaina Ahmed, Jason Green, Iya Dubson and Samy I. McFarlane

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

Cite this article:

Normal Style
Pramod Theetha Kariyanna, Apoorva Jayarangaiah, Mohammed Al-Sadawi, Rodaina Ahmed, Jason Green, Iya Dubson, Samy I. McFarlane. A Rare Case of Second Degree Mobitz Type II AV Block Associated with Cocaine Use. American Journal of Medical Case Reports. Vol. 6, No. 7, 2018, pp 146-148. http://pubs.sciepub.com/ajmcr/6/7/7
MLA Style
Kariyanna, Pramod Theetha, et al. "A Rare Case of Second Degree Mobitz Type II AV Block Associated with Cocaine Use." American Journal of Medical Case Reports 6.7 (2018): 146-148.
APA Style
Kariyanna, P. T. , Jayarangaiah, A. , Al-Sadawi, M. , Ahmed, R. , Green, J. , Dubson, I. , & McFarlane, S. I. (2018). A Rare Case of Second Degree Mobitz Type II AV Block Associated with Cocaine Use. American Journal of Medical Case Reports, 6(7), 146-148.
Chicago Style
Kariyanna, Pramod Theetha, Apoorva Jayarangaiah, Mohammed Al-Sadawi, Rodaina Ahmed, Jason Green, Iya Dubson, and Samy I. McFarlane. "A Rare Case of Second Degree Mobitz Type II AV Block Associated with Cocaine Use." American Journal of Medical Case Reports 6, no. 7 (2018): 146-148.
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[1]  Center for Behavioral Health Statistics and Quality (CBHSQ). Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015. HHS Publication No. SMA 15-4927, NSDUH Series H-50.
In article      
 
[2]  Afonso, L.; Mohammad, T.; Thatai, D. Crack whips the heart: a review of the cardiovascular toxicity of cocaine. Am. J. Cardiol., 2007, 100(6), 1040-1043.
In article      View Article  PubMed
 
[3]  Maraj, S.; Figueredo, V.M.; Lynn Morris, D. Cocaine and the heart. Clin. Cardiol., 2010, 33(5), 264-269.
In article      View Article  PubMed
 
[4]  Vasica, G.; Tennant, C.C. Cocaine use and cardiovascular complications. Med. J. Aust., 2002, 177(5), 260-262.
In article      PubMed
 
[5]  Jacobsen TN, Grayburn PA, Snyder RW, Hansen J, Chavoshan B, Landau C, Lange RA, Hillis LD, Victor RG. Effects of intranasal cocaine on sympathetic nerve discharge in humans. The Journal of clinical investigation. 1997 Feb 15; 99(4):628-34.
In article      View Article  PubMed
 
[6]  Seelig MG. History of cocaine as a local anesthetic. Journal of the American Medical Association. 1941 Oct 11; 117(15):1284.
In article      View Article
 
[7]  Magnano AR, Talathoti NB, Hallur R et al. Effect of acute cocaine administration on the QTc interval of habitual users. Am. J. Cardiol. 97, 1244-1246 (2006).
In article      View Article  PubMed
 
[8]  Javaid JI, Fischman MW, Schuster CR et al. Cocaine plasma concentration: relation to physiological and subjective effects in humans. Science 202, 227-228 (1978).
In article      View Article  PubMed
 
[9]  Orr D, Jones I. Anaesthesia for laryngoscopy. a comparison of the cardiovascular effects of cocaine and lignocaine. Anaesthesia 23, 194-202 (1968).
In article      View Article  PubMed
 
[10]  Hollander JE, Hoffman RS, Gennis P et al. Prospective multicenter evaluation of cocaine-associated chest pain. Cocaine Associated Chest Pain (COCHPA) Study Group. Acad. Emerg. Med. 1, 330-339 (1994).
In article      View Article
 
[11]  Chakko S, Fernandez A, Mellman TA et al. Cardiac manifestations of cocaine abuse: a cross-sectional study of asymptomatic men chronically abusing ‘crack’ cocaine. J. Am. Coll. Cardiol. 20, 1168-1174 (1992).
In article      View Article
 
[12]  Kalimullah EA, Bryant SM. Case files of the medical toxicology fellowship at the toxikon consortium in Chicago: cocaine-associated wide-complex dysrhythmias and cardiac arrest-treatment nuances and controversies. Journal of Medical Toxicology. 2008 Dec 1; 4(4): 277-83.
In article      View Article  PubMed
 
[13]  Weiner RB, Weiner SD, Yurchak PM. Removing the mask. The American journal of medicine. 2008 Feb 1; 121(2): 113-6.
In article      View Article  PubMed
 
[14]  Bertos-Polo J, Guti C. Aborted sudden death, transient Brugada pattern, and wide QRS dysrrhythmias after massive cocaine ingestion. Journal of electrocardiology. 2001 Oct 1; 34(4): 345-9.
In article      View Article  PubMed
 
[15]  Kerns II W, Garvey L, Owens J. Cocaine-induced wide complex dysrhythmia. The Journal of emergency medicine. 1997 May 1; 15(3): 321-9.
In article      View Article
 
[16]  Grigorov V, Goldberg L, Foccard JP. Cardiovascular complications of acute cocaine poisoning: a clinical case report: case report. Cardiovascular Journal of South Africa. 2004 May 1; 15(3): 139-42.
In article      PubMed
 
[17]  Om A, Ellenbogen KA, Vetrovec GW. Cocaine-induced bradyarrhythmias. American heart journal. 1992 Jul 1; 124(1): 232-4.
In article      View Article
 
[18]  Aryana A, Mooss AN. ST elevation alternans in presence of profound myocardial ischemia and injury induced by cocaine toxicity. Clinical Cardiology: An International Indexed and Peer-Reviewed Journal for Advances in the Treatment of Cardiovascular Disease. 2009 Jul; 32(7):E43-4.
In article      View Article  PubMed
 
[19]  Tanen DA, Greame KA, Curry SC, Curry S. Crack cocaine ingestion with prolonged toxicity requiring electrical pacing. Journal of Toxicology: Clinical Toxicology. 2000 Jan 1; 38(6): 653-7.
In article      View Article  PubMed
 
[20]  Isner JM, Estes III NM, Thompson PD, Costanzo-Nordin MR, Subramanian R, Miller G, Katsas G, Sweeney K, Sturner WQ. Acute cardiac events temporally related to cocaine abuse. New England Journal of Medicine. 1986 Dec 4; 315(23): 1438-43.
In article      View Article  PubMed
 
[21]  Stenberg RG, Winniford MD, Hillis LD, Dowling GP, Buja LM. Simultaneous acute thrombosis of two major coronary arteries following intravenous cocaine use. Archives of pathology & laboratory medicine. 1989 May; 113(5): 521-4.
In article      PubMed
 
[22]  Schwartz AB, Janzen D, Jones RT. Electrophysiologic effects of cocaine on the canine ventricle. Journal of cardiovascular pharmacology. 1989 Feb; 13(2): 253-7.
In article      View Article  PubMed
 
[23]  Temesy-Armos PN, Fraker JT, Brewster PS, Wilkerson RD. The effects of cocaine on cardiac electrophysiology in conscious, unsedated dogs. Journal of cardiovascular pharmacology. 1992 Jun; 19(6): 883-91.
In article      View Article  PubMed
 
[24]  Tracy CM, Bachenheimer L, Solomon A, Cohen MM, Kuhn FE, Jain R, Corr PB, Gillis RA. Evidence that cocaine slows cardiac conduction by an action on both AV nodal and His-Purkinje tissue in the dog. Journal of electrocardiology. 1991 Jul 1; 24(3): 257-62.
In article      View Article
 
[25]  Przywara DA, Dambach GE. Direct actions of cocaine on cardiac cellular electrical activity. Circulation research. 1989 Jul 1; 65(1): 185-92.
In article      View Article  PubMed
 
[26]  Magnano AR, Talathoti NB, Hallur R, Jurus DT, Dizon J, Holleran S, Bloomfield DM, Collins E, Garan H. Effect of acute cocaine administration on the QTc interval of habitual users. American Journal of Cardiology. 2006 Apr 15; 97(8): 1244-6.
In article      View Article  PubMed
 
[27]  Kajdasz DK, Moore JW, Donepudi H, Cochrane CE, Malcolm RJ. Cardiac and mood-related changes during short-term abstinence from crack cocaine: the identification of possible withdrawal phenomena. The American journal of drug and alcohol abuse. 1999 Jan 1; 25(4): 629-37.
In article      View Article  PubMed
 
[28]  Hollander JE, Lozano M, Fairweather P, Goldstein E, Gennis P, Brogan GX, Cooling D, Thode HC, Gallagher EJ. “Abnormal” electrocardiograms in patients with cocaine-associated chest pain are due to “normal” variants. The Journal of emergency medicine. 1994 Mar 1; 12(2): 199-205.
In article      View Article
 
[29]  Levin KH, Copersino ML, Epstein D, Boyd SJ, Gorelick DA. Longitudinal ECG changes in cocaine users during extended abstinence. Drug & Alcohol Dependence. 2008 May 1; 95(1): 160-3.
In article      View Article  PubMed