Case report: We describe here a singular case in wich a moderate oral charge of Nimesulide was followed by a true electrical storm, without any other plausible cause. 3.5.2003: an othewise healty 45 ys old man, without family history for cardiac sudden death, track-driver, take at work tree pills of Numesulide 100 mg, within 40 minutes, for back and shoulder pain. Nearly twenty minutes after the last assunction he felt suddenly faint , with diaphoresis, palpitation, dizzines, syncope. In ER, the ECG shown significant ventricular arrhythmias, consisting in more o less prolonged rapid (170-220 bpm) access of monomorfic ventricular tachicardia, with QRS morphology consistent with right origin . Tipically, the arrhythmic access were strongly symptomathic, but self-extinguish (in this like torsade de pointes) , followed by precocious relapse. The patient never in the past felt similar symptom. The arrhythmic storm was resistent to any phamacological treatment we have tried: magnesium sulfate infusion, amiodarone infusion, lidocaine infusion, propafenone infusion, and ended up only nearly two hours after admission, without any relapse (when presumibly the blood level of nimesulide fall substantially). All biochemical data (including myocardial necrosis’s serum markers) were normal. The basal ECG (including QT interval ) was normal . Coronary angiography shown normal coronaries arteries. The patients refused electrophysiological endocavitary investigation and cardiac magnetic resonance exam (claustrophobia) . At follow up (almost ten years!) the patient (without any antiarrhythmic therapy) was asimptomathic, his dinamic ECG shows only sporadic isolated ventricular premature beats, his echocardiogram was normal, his stress-test was normal. He never felt again similar symptoms. He never taken again Nimesulide. Although is know that a lot of drug may trigger ventricular (even letal) arrhythmias, we don’t have any awareness that Nimesulide, one of the FANS more used in western countries, may have a similar potenctial adverse effect. The likely link between the drug assunction and the arrhythmic storm was strongly suggest by the temporal relationship between the two events and by the absence on any other plausibile cause . The absence of compliance toward cardiac RMN and electrophysiological investigation suggest us great caution, and we waited a lot of years before describe this case, in order to avoid any arrhythmic recurrent idiophatic syndrome. Nimesulide have in its molecular structure a methanesulphonanilide group (CH3.SO2.NH-), like dofelitide . Dofelitide, exerts Class III antiarrhythmic effects by inhibiting the cardiac rapid delayed rectifier potasium current (I (Kr)) encoded by HERG . This potassium-current inibition may in turn have a potenctial pro-arrhythmic effect, due to early after depolarization occurrence So, it 's not impossible that also nimesulide has a similar effect on the potassium current, with the same potectial pro-arrhythmic effects.
Conclusions: Addition of ivabradine to optimum medical treatment seems to improve functional status, exercise capacity and diastolic function.