Internal medicine resident Wilmington, Delaware, United States
Disclosure(s):
Bryce N. Grohol, DO, PharmD: No financial relationships to disclose
Background: Methadone is a full mu opioid receptor agonist used to suppress withdrawal symptoms. Chronic methadone use can prolong QT interval with this effect being exacerbated by various stressors. We present a case of polymorphic VT ina patient on chronic methadone who presented with an acute infection.
Methods: A 63-year-old male with a history of opioid use disorder on methadone and non ischemic cardiomyopathy with an ejection fraction of 35% presented with dyspnea associated with a leukocytosis. He decompensated upon arrival with concern for flash pulmonary edema necessitating intubation. Upon admission to the cardiac intensive care unit he developed polymorphic VT (PMVT). There was concern for bradycardia associated with these events concerning for R-on-T phenomenon. The patient received several defibrillations and ultimate was initiated on lidocaine due to amiodarone being unable to suppress PMVT. Clinical course resulted in the implantation of a CRT-D device. Methadone was continued on discharge given prolonged history of opioid use disorder.
Outcome: Chronic methadone users are often hospitalized for a broad range of symptoms. Our patient has a history of nonischemic cardiomyopathy and the chronic methadone use resulted in a reduced threshold to withstand other stressors which may provoke malignant arrythmias. In our patient, despite his polymorphic ventricular tachycardia being from a reversible cause, he met criteria for secondary prevention CRT-D placement.
Conclusion: Chronic methadone use with physiologic stressors is a perfect storm for malignant arrythmia. Telemetry monitoring and caution with QT prolonging agents should be taken in patients presenting with other stressors. Careful consideration for placement of devices for patients who need continued therapy with methadone with prior PMVT should be taken.
