Page 41 - JSOM Spring 2020

Case Report

Stimulant-Induced Atrial Flutter in a Remote Setting

Aaron C. Thomas, MD*; Justine Pagenhardt, MD; Brenden Balcik, MD

ABSTRACT
Atrial flutter and atrial fibrillation are among the most com- to date, and few human cases have reported arrhythmia due
monly encountered cardiac arrhythmias; however, there is a to caffeine use. However, one case of an adolescent male with
dearth of clinical trials or case studies regarding its occurrence caffeine-induced atrial fibrillation self-converted after simple
in the setting of stimulants such as caffeine and nicotine in intravenous fluid administration, whereas another in the same
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otherwise healthy young patients. Described here is a case of report converted after intravenous digoxin. A study in dogs
a 29-year-old physically fit white man without significant past found that increasing doses of caffeine can decrease propensity
medical history who presented in stable condition complaining for atrial fibrillation, whereas another canine study demon-
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only of palpitations. He was found to have atrial flutter with- strated increased risk of cardiac arrhythmias in general with
out rapid ventricular response on cardiac monitoring, most caffeine. One study on human atrial myocytes demonstrated
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likely due to concomitant presence of high levels of nicotine that adenosine-mediated pathways, such as that stimulated by
and caffeine via chewing tobacco and energy drinks. He was caffeine, contribute to the initiation of atrial fibrillation in sus-
treated conservatively with vagal maneuvers and intravenous ceptible patients. Furthermore, guarana, a component of many
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fluids with complete resolution of symptoms and electrocar- energy drinks and performance supplements, has been shown in
diographic abnormalities within 14 hours. This demonstrates planarian models to increase stimulation in combination with
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an alternate conservative treatment strategy in appropriately caffeine over caffeine alone. Animal studies have demonstrated
risk stratified patients who present in an austere field setting dose-dependent arrhythmogenicity of nicotine as well. Reports
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with limited resources. of healthy young patients influenced by multiple stimulants ex-
periencing cardiac arrhythmias are rare, however. Furthermore,
Keywords: atrial flutter; caffeine; nicotine; vagal maneuver; current treatment algorithms advocate for early administration
athlete of medications and electrical conversion, even in the stable pa-
tient without other risk stratification or trigger identification. 10

Introduction Case Presentation
Atrial flutter is estimated to affect 33.5 million people world- A 29-year-old physically fit white man serving in the US mili-
wide, and in the United States there are estimated to be about tary Special Operations Forces with no significant past medical
200,000 new cases of atrial flutter every year. It is considered history presented in an austere field setting with palpitations
by many to be on a spectrum of cardiac arrhythmias to in- first noticed when preparing to exercise approximately 2 hours
clude atrial fibrillation, which is tied to increased cardiovas- earlier. He denied headache, chest pain, dizziness, lightheaded-
cular disease with other risk factors such as hypertension and ness, fatigue, shortness of breath, or exercise intolerance. He
1,2
atherosclerosis. Presentation can be nonspecific including had intermittently used chewing tobacco for several years and
symptoms such as palpitations, dizziness, lightheadedness, over the last week had increased the daily amount used by
fatigue, or shortness of breath. In otherwise healthy young 2- to 3-fold. He also admitted to consuming two or three en-
™
people, these conditions are relatively uncommon and when ergy drinks (Rip-It ) the day of presentation, each containing
present often prompt extensive workup looking for structural approximately 100mg caffeine, 1000mg taurine, 3mg guarana
or electrophysiologic abnormalities. seed extract, and 25g sugar. Further questioning revealed that
his typical fluid intake had been decreased over the preceding
There is growing evidence that physically active people may be 24 hours, noting that he had not urinated in the 4 to 6 hours
at higher risk of developing atrial fibrillation. Studies on endur- before presentation and that last urine was darker yellow than
ance athletes have suggested that mechanisms for this include usual. He denied using any prescription or over-the-counter
atrial ectopy, autonomic influence, atrial remodeling in re- medications and had never taken any long-term prescription
3
sponse to exercise, or fibrosis and inflammation. Complicating medications. There was no personal or family history of con-
the picture, the population as a whole is exposed to a multitude genital heart disease or cardiovascular disease.
of substances that often contain caffeine or other stimulants,
primarily tobacco, coffee, and exercise supplements or energy His physical examination revealed an irregularly irregular
drinks. There are mixed data on the arrhythmogenicity of these pulse with rate in the 110s, blood pressure of 110s/70s, and
*Correspondence to thomas.aaronc@gmail.com
Drs Thomas, Pagenhardt, and Balcik are affiliated with the West Virginia University Department of Emergency Medicine.

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