Abstract

A 38 years-old woman was admitted to the Emergency Room in cardiogenic shock and obnubilated. Her past history was known because of a recent ablation of an AV accessory pathway, previously refractory to flecainide, and included a congenital hydrocephalus with reduction of mental abilities. Flecainide had been suspended since the ablation and no information on recent drug assumption was available. The EKG showed sinus bradycardia, a prolonged P wave, 1° AVB, RBBB and LAFB (QRS 200 ms) (Figure 1). Routine laboratory tests were unremarkable. Severe biventricular dysfunction was found (LVEF 35%) at echocardiogram. Activated charcoal was administered. Pulmonary embolism and cerebrovascular events were excluded with a CT scan. The patient was then intubated and admitted to the Intensive Care Unit. Support fluid therapy and low-dose inotropic drugs were started. Over the next 36 hours EKG returned to baseline (Figure 2) and LVEF improved to 50%. Flecainide plasma levels were 2600 ng/ml at 12 hours and 1000 ng/ml at 26 hours from admission (NR 200-1000 ng/ml). After recovery, the patient confessed inappropriate flecainide assumption and was therefore referred to psychiatric consult.