Treatment Of Hepatitis C Virus With Peginterferon and Ribavirin May

Treatment Of Hepatitis C Virus With Peginterferon and Ribavirin May

Treatment Of Hepatitis C Virus With Peginterferon and Ribavirin May Be Triggered To the Atrioventricular
Nodal Reentrant Tachycardia In An Intensive Care Unit Patient
Mustafa Yıldız1, Ahmet Çağrı Aykan2, Banu Şahin Yıldız3, Gönenç Kocabay1
1 İstanbul Kartal Koşuyolu Yüksek İhtisas Eğitim ve Araştırma Hastanesi, Kardiyoloji Kliniği, İstanbul, Türkiye
2 Trabzon Ahi Evren Göğüs Kalp ve Damar Cerrahisi Eğitim ve Araştırma Hastanesi, Kardiyoloji Kliniğ, Trabzon,
Türkiye
3 İstanbul Kartal Dr. Lütfi Kırdar Eğitim ve Araştırma Hastanesi, Kardiyoloji Kliniği, İstanbul, Türkiye
ABSTRACT
Treatment of Hepatitis C virus (HCV) with of peginterferon α2b (peg-IFN) and ribavirin is more effective than
conventional interferon and ribavirin. Despite of the important effects of peg-IFN and ribavirin therapy, many side
effects such as fever, fatigue, anxiety, irritability, neutropenia and thrombocytopenia may be seen. Also, cardiac
arrhythmias and syncope are rare consequence of therapy with peg-IFN. In this study, we report an intensive care
unit patient who developed atrioventricular nodal reentrant tachycardia that is the most common type of reentrant
supraventricular tachycardia and presyncopal attack during peg-IFN and ribavirin therapy.
Keywords: Hepatitis C virus, peginterferon, ribavirin, atrioventricular nodal reentrant tachycardia.
Yoğun Bakım Hastasında Hepatit C Virüsünün Peginterferon ve Ribavirin ile Tedavisi Atriyo Ventriküler
Nodal Reenteran Taşikardiye Neden Olabilir
Mustafa Yıldız1, Ahmet Çağrı Aykan2, Banu Şahin Yıldız3, Gönenç Kocabay1
1 İstanbul Kartal Koşuyolu Yüksek İhtisas Eğitim ve Araştırma Hastanesi, Kardiyoloji Kliniği, İstanbul, Türkiye
2 Trabzon Ahi Evren Göğüs Kalp ve Damar Cerrahisi Eğitim ve Araştırma Hastanesi, Kardiyoloji Kliniğ, Trabzon,
Türkiye
3 İstanbul Kartal Dr. Lütfi Kırdar Eğitim ve Araştırma Hastanesi, Kardiyoloji Kliniği, İstanbul, Türkiye
ÖZET
Hepatit C virus (HCV) tedavisinde peginterferon α2b (peg-IFN) ve ribavirin tedavisi konvansiyonel interferon ve
ribavirin tedavisinden daha etkilidir. Peg-IFN ve ribavirin tedavisinin önemli etkilerinin yanında ateş, halsizlik,
heyecan, huzursuzluk, nötropeni, ve trombositopeni gibi bir çok yan etki görülebilir. Ayrıca kardiyak aritmiler ve
senkop gibi nadir olaylar da peg-NIF tedisine bağlı gelişebilir. Bizler bu çalışmada peg-INF ve ribarivirin tedavisi
sırasında presenkop atağı ve reenteran taşikardilerin en sık formu olan atriyoventriküler nodal reenteran taişkardi
gelişen bir yoğun bakım hastasını sunuyoruz.
Anahtar Kelimeler: Hepatit C virüsü, peginterferon, ribavirin, atriyoventriküler nodal reenteran taşikardi.
Geliş Tarihi: 02.12.2013 - Kabul Tarihi: 05.12.2013
Introduction
Hepatitis C virus (HCV) infection is often asymptomatic, but chronic infection can lead to scarring of the liver and
ultimately to cirrhosis that is generally apparent after many years. Current treatment is a combination of
peginterferon α2b (peg-IFN) and ribavirin for a period of 24 or 48 weeks (1). Treatment of HCV with peg-IFN and
ribavirin has shown to be more effective than conventional interferon and ribavirin (2). Despite of the important
effects of peg-IFN and ribavirin therapy, many side effects such as fever, fatigue, anxiety, irritability, neutropenia
and thrombocytopenia have been reported (2). Also, cardiac arrhythmias and syncope are rare consequence of
therapy with peg-IFN (3). In this study, we report an intensive care unit patient who developed atrioventricular nodal
reentrant tachycardia (AVNRT) that is the most common type of reentrant supraventricular tachycardia and
presyncopal attack during peg-IFN and ribavirin therapy.
Case
A 46-year-old man who developed palpitation and presyncopal attack within 10 weeks after starting therapy with
peg-IFN (150 μg/week) and ribavirin (1200 mg/day) for the treatment of chronic HCV. He had palpitation about 20
years ago and hadn’t any medications. In intensive care unit, the surface electrocardiogram (ECG) and 24 hours
Holter ECG revealed AVNRT (Figure 1A). After iv 5 mg metoprolol the tachycardia was stopped (Figure 1B).
Transthoracic echocardiography, thyroid hormones and other routine laboratory tests were normal. We offered the
electrophysiology study and cathater ablation therapy to the patient, but he refused it. After AVNRT attack, the dose
of peg-IFN was decreased (120 μg/week) and metoprolol 50 mg/day was initiated. After 10 weeks, AVNRT was
occured again during infusion. The patient refused the ablation therapy again. Therefore, metoprolol was increased
100 mg/day. Close follow up revealed neither palpitation nor presyncope and HCV-RNA was undetectable at 24 and
48 weeks of treatment.
Discussion
Side effects of IFN and ribavirin combination therapy for HCV have been documented (2); however, cardiac
arrhythmias are rare reported. Moreover, there is not AVNRT associated with peg-IFN in the literature.
AVNRT is the most common regular supraventricular tachycardia in intensive care unit originating above the His
bundle (4). It occurs when a reentry circuit forms within or just next to the atrioventricular node. The circuit usually
involves two anatomical pathways (dual AV nodal physiology): the fast pathway and the slow pathway which is
usually targeted for ablation (5). The slow pathway is located inferiorly and slightly posterior to the atrioventricular
node, often following the anterior margin of the coronary sinus. The fast pathway is usually located just superior and
posterior to the atrioventricular node. The therapy of AVNRT can be used atrioventricular nodal slowing drugs such
as adenosine, beta blockers, as in our case, or non-dihydropyridine calcium channel blockers. Also, patients can
undergo an electrophysiology study for cure via generally slow pathway ablation.
In this case, this drugs may cause atrial premature complexes during infusion, and atrial premature complexes may
affect dual pathway physiology. Finally, AVNRT may be triggered. For cure this rhythm, we offered the
electrophysiology study and catheter ablation therapy to the patient, but he refused it. So, we had continued the
medical therapy with beta blockers.
Conflict of interest: None.
References
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during hepatitis C treatment: a case report. Cases J 2009;2:7429.
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5. Yildiz M, Aykan A.C., Kahveci G, Demir S, Ozkan M. Transvenous Radiofrequency Ablation Theraphy as
an Effective and Safe Method for The Treatment of The Slow Pathway Of Atrioventricular Nodal ReEntrant Tachycardia Koşuyolu Kalp Dergisi 2011;14:51-5.
Figure Legends:
Figure 1A. The surface electrocardiogram revealed AVNRT. After iv 5 mg metoprolol the tachycardia was stopped
(Figure 1B).