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Dr. Andrew Rynne

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What causes arrhythmia while lying down?

Answered by
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Dr. Ilir Sharka

Cardiologist

Practicing since :2001

Answered : 6328 Questions

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Posted on Wed, 13 Mar 2019 in General Health
Question: Hi - I am copying my last question below as it has all the information about me in it. This new question is related again to the Mobitz Type I (Wenckebach) issue I have and medication. Thank you for suggesting a prolonged ECG next time it happens - I think this is important too. Interestly, the arrythmia is worse when I am laying down - why would that be?

From looking online, I thought that Mobitz Type I was to do with PR interval prolongation, not QT? If a drug prolongs the QT interval, is that also not good for the Mobitz Type I issue?

So if I have this issue, I shouldn't be on Citalopram? How about Tramadol, Oxazapem and Codeine? A doctor also wants to put me on a small dose of Quetiapine for sleep - 25 mg - but should this one be avoided as well? Also, I have just been given some Norspan patches (buprenorphine) 5 to help while reducing off Tramadol - should I avoid that one as well?

I should mention that Lyrica also caused this arrythmia in me (maybe in combination with the Citalopram) - so I went off it.

Thinking of my underlying issues - Fibromyalgia (and chronic pain in neck and head) and moderate anxiety, along with this tendency to Mobitz type I arrythmia, which medications would you recommend?

Very many thanks,
Louise



Weight 92 kg Height 175 cm Age: 54
Diagnosed conditions: Fibromyalgia, C2/3 facet joint damage (MVA), C6/7 nerve root impingement (MVA), RSI right wrist (35 years), plantar fasciitis (comes and goes), sacro-iliac pain (comes and goes).
Recent blood test: bit low in Vitamin D.
Medications: Tramadol 100 mg/day, Codeine 30 mg day PRN, Citalopram 10 mg, Oxazepam 7.5 mg
Hi – I feel very breathless on little exertion and my heart rate increases a lot – for example just bending down to do up shoelaces. However, I can go for a 50 minute walk and not get too out of breath (except on hills). Having trouble sleeping for last two months as came off Stillnox after eight years on it. Sometimes used codeine, Temazepam and periactin to sleep. But last night took none of these and still feel very short of breath. Doctor has listened to chest – all ok. Might have a bit of reflux at night – not sure – but I think morning coughing could be due to that. Put on 10 kg in a six month period recently – it’s plateaued at 92 kg for about three months. Also feel pretty exhausted and tired and lacking motivation quite a bit of the time. Thanks
doctor
Answered by Dr. Ilir Sharka 1 hour later
Brief Answer:

I would explain as follows:

Detailed Answer:

Hello,

Regarding your concern, I would explain that there is no direct connection between the Mobitz type I and the drugs that may lead to QT prolongation (including citalopram and Seroquel).

But, you should know that these drugs can lead to increased risk for lifethreatening ventricular arrhythmia in patients with Mobitz type I. That is why they should be used with caution and in low doses.

Regarding the other drugs that you are taking, I would not recommend taking tramadol and codeine for a long time. They are both opioids and should not be taken concomitantly.

Besides, their prolonged use can lead to addiction and tolerance.

Another point to consider is the interaction between them (haloperidol and codeine) and Citalopram, by increasing serotonin levels.

The same is for buprenorphine. It can lead to shortness of breath as a possible adverse effect (which may explain your complaints) and also increase serotonin levels, by interacting with citalopram.

For this reason, I would not recommend using it for a long time.

That is why I would not recommend taking them anymore. But it is important to gradually lower the dose until stopping them, in order to avoid withdrawal syndrome.

Regarding Seroquel, it can lead to QT prolongation syndrome too.

The combination of Seroquel and Citalopram can lead to potential interaction with each other, by increasing the risk for cardiac arrhythmia.

So, I would not encourage you to start Seroquel.

Regarding Oxazepam, it is OK to take it for a short period of time, as it does not influence your cardiac function.

But its prolonged use can lead to addiction and tolerance (like all other benzodiazepines).

You should discuss with your doctor on the above issues.

Hope I have answered your query. Let me know if I can assist you further.

Take care

Rgards,
Dr Ilir Sharka, Cardiologist
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka 18 hours later
Dear Dr Iliri,

Thank you very much for all the advice - I can see that having a tendency to Mobitz I is going to restrict my choice of medications quite a lot. I'm a bit confused as to why I have it though - is one born with it? Does it mean my brothers would have it as well? Or does it only show up when you take the wrong medications? What percentage of people have it? - lots of questions...

So I guess the question remains as to when I come off Tramadol and Citalopram and other opiates, what medications are suitable for me to take for pain and anxiety? Or is that a question for a GP?

Many thanks,
Louise
doctor
Answered by Dr. Ilir Sharka 3 hours later
Brief Answer:

I would explain as follows:

Detailed Answer:

Hello,

This abnormality is usually not hereditary.

It could be related to a structural defect of the heart, born or caused by myocardial tissues damage in many cardiac disorders (myocarditis, myocardial infarction, cardiac surgery).

Some drugs which may cause this abnormality are calcium channel blockers, lithium, beta-blockers, digoxin, etc.

It can be related also to increased vagal tone in sportspersons.

Some other metabolic causes that may lead to this situation are amyloidosis, hyperthyroidism, hemochromatosis, sarcoidosis, Lyme disease, connective tissues disorders, etc..

The prevalence of this disorder in healthy persons goes 2-4%, based on different population studies.

I would not recommend opioids for the pain. Painkillers like acetaminophen, ibuprofen are better tolerated in your clinical situation.

Sertraline and paroxetine are SSRI drugs (like Citalopram) which do not cause QT prolongation as much as Citalopram or other drugs of this pharmacological group.

So, you can switch from Citalopram to Sertraline for the management of anxiety.


Another possible treatment option besides Citalopram in low doses would be Pregabalin or Gabapentin, which are anti-epileptic drugs used to treat chronic pain. They are well tolerated.

You should discuss with your doctor on the above treatment options.

Hope I have answered your query. Let me know if I can assist you further.

Take care

Regards,
Dr Ilir Sharka, Cardiologist
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka 2 days later
Dear Dr Iliri many thanks for all your help! If I hadn't have had any medications which manifest the arrhythmia, does that mean that it wouldn't ever have been found out? Is it the type of thing that is just like a predisposition that just comes out under certain circumstances? How can you know in advance whether someone has it or not? I will try not to ask you any more questions haha thanks very much, Louise
doctor
Answered by Dr. Ilir Sharka 9 hours later
Brief Answer:

My opinion as follows:

Detailed Answer:

Hello,

The above-mentioned drugs may have an important role in predisposing for heart rhythm disorders as we discussed before.

This triggering effect is higher in individuals with congenital or several structural cardiac disorders.

Nevertheless, besides the fact when a patient is previously diagnosed with a congenital heart disorder in childhood (congenital long QT syndrome, heart block, etc.) or a structural cardiac disorder during his life, in other cases it is almost impossible to predict whether an individual will experience a cardiac rhythm issue.

But, when we are in front of certain drugs that are well-known to increase the risk of triggering arrhythmia, we are quite sure that counseling for a screening strategy and a careful follow up is quite beneficial at reducing the risk of arrhythmia by preventing and timely correcting any appearing abnormality.

In general, a careful and frequent follow-up by means of periodic ECGs and lab tests (including blood electrolytes) is all that is necessary in the majority of cases.

In conclusion, I would say that you are right! We could not be sure of a certain heart issue and especially cardiac rhythm issue if the patient has not been previously studied as part of a screening program or purposely due to an indication of starting a specific therapy or procedure.

I remain at your disposal for any further discussions in case you will need!

Hope I have answered your query.

Take care

Regards,
Dr Ilir Sharka, Cardiologist
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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