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Arrhythmia 2015;16(1):55-58
ECG & EP CASES
Ventricular Tachycardia with Two Distinct
Morphologies Caused by Herbal
Medicine Containing Ephedra sinica
Seung Yong Shin, MD, PhD.
ABSTRACT
Division of Cardiology, Department of Internal Medicine,
College of Medicine, Chung-Ang University, Seoul, Korea
Received: November 2, 2014
Revision Received: February 21, 2015
Accepted: March 26, 2015
Correspondence: Seung Yong Shin, MD, PhD,
Heart Research Institute, Cardiovascular and
Arrhythmia Center, Chung-Ang University
Hospital, College of Medicine, Chung-Ang
University, 102, Heukseok Ro, Dongjak Gu,
Seoul, 156-755, Korea
Tel: +82-2-6299-2871, Fax: +82-2-823-0160
E-mail: [email protected],
[email protected]
Copyright © 2015 The Official Journal of Korean Heart
Rhythm Society Editorial Board & MMK Co., Ltd.
A 77-year-old man presented to the emergency department with
dizziness and a fluttering sensation in the chest. Electrocardiography
demonstrated sustained monomorphic ventricular tachycardia with
two different morphologies (right bundle branch block, left bundle
branch block). The patient had taken herbal medicine containing
Ephedra sinica for two days. Based on the findings of a thorough
work up, I concluded that both of the ventricular tachycardias might
have been caused by this herbal medicine.
Key Words: Tachycardia, ventricular, Herbal medicine, Ephedra si-
nica
Introduction
medicine containing Ephedra sinica (Ma Huang).
Ephedra alkaloids are a group of sympathomimetic compounds
Case
derived from the shrubs of the Ephedra genus. These alkaloids are
structurally similar to amphetamines and catecholamines, and
A 77-year-old man presented to the emergency department
possess both α- and β-adrenergic activity. Ephedra alkaloids have
with a fluttering sensation in the chest and sudden onset dyspnea.
been used in traditional folk remedies, particularly in China, for
On initial presentation, the vital signs were as follows: heart rate,
millennia. The principle alkaloid ephedrine was first isolated in
208 beats per minute (bpm); respiratory rate, 22 breaths per
1885, and has been used in modern medicine as a bronchodilator,
minute; and body temperature, 36.6°C. Although the patient had
decongestant, and vasopressor. Ephedra extracts are also
weak femoral pulses and a blood pressure of 60/40 mmHg, he
commonly taken to enhance weight loss and athletic performance.
seems to be mentally alert when in a supine position. Breath
Ephedra-containing dietary supplements were banned by the
sounds were clear, and no evidence of wheezing or crackling.
American Food and Drug Administration in 2004 because of
However, the heart sound was distorted because of tachycardia.
significant adverse effects. Between 1995 and 1997, 37 cases of
Twelve-lead electrocardiography (ECG; Figure. 1A) initially
adverse effects were reported and predominantly involved serious
showed sustained monomorphic VT (208 bpm), a right bundle
cardiovascular events (e.g., stroke, myocardial infarction, sudden
branch block (RBBB) pattern in the precordial leads, and left axis
cardiac death), despite no underlying cardiovascular disease.
deviation. Biphasic electrical cardioversion (200 J) successfully
1
2
3
3
Here, I report a case of ventricular tachycardia (VT) with two
terminated the VT through conversion to atrial fibrillation
distinct morphologies caused by the consumption of herbal
(Figure. 1B). After 1 hour, a further sustained monomorphic VT
55
Arrhythmia 2015;16(1):55-58
A
B
C
D
Figure 1. Twelve-lead electrocardiograms (ECG).
(A) The initial ECG shows fast monomorphic ventricular tachycardia (208 bpm), a right bundle branch block in the precordial leads, and left axis
deviation. VT was inferred based on the interpretation of the ECG with the captured beat (arrow).
(B) Atrial fibrillation is observed following electrical cardioversion.
(C) The ECG of the second VT (210 bpm) shows a left bundle branch block pattern and superior axis deviation.
(D) The ECG shows restored sinus rhythm after additional electrical cardioversion.
56
Ventricular Tachycardia by Ephedra sinica
(210 bpm) developed spontaneously, with a QRS morphology
cardiovascular events is largely attributable to the
that was indicative of left BBB (LBBB) and superior axis
sympathomimetic activity of these alkaloids.1 That is, these
deviation (Figure. 1C). Biphasic electrical cardioversion (200 J)
compounds directly stimulate α1, β1, and β2 adrenergic receptors
was reattempted, and sinus rhythm was successfully restored
and can thereby result in vasoconstriction, bronchodilation,
(Figure. 1D).
increased heart rate, enhanced myocardial contractility, and
After the treatment, the possible causes of the VT were
increased automaticity. Such compounds also shorten cardiac
considered, including anemia, electrolyte imbalance, hypoxemia,
refractory periods and can therefore facilitate the development of
coronary artery disease, cardiomyopathy, congenital heart disease,
cardiac arrhythmogenesis.8 The long-term use of ephedrine may
or drug effects. Laboratory result revealed normal serum
lead to the cardiomyopathy typically observed during
creatinine levels, electrolyte levels, and arterial blood gases.
catecholamine excess.7
Similarly, ECG showed a normal left ventricular ejection fraction
To date, there has been no report of VT with two distinct QRS
(65%) with no significant valve degeneration or structural
morphologies (RBBB and LBBB) caused by E. sinica in patients.
abnormalities. Although coronary angiography revealed a stenosis
The present case is also distinct from previously reported cases of
of 70% in both the proximal part of the left circumflex coronary
VT6,7 in several additional respects: 1) the sustained distinct
artery and the posterior descending artery, I decided to administer
monomorphic VTs originated from different ventricles; 2) the
pharmacologic treatment based on the presence of normal blood
patient had taken unknown but small doses of E. sinica (four in
flow and absence of angina.
total); and 3) the ingestion of the herbal medication had been of a
The patient had been diagnosed with chronic obstructive
relatively short duration (two days).
pulmonary disease 30 years prior to admission. He had a history
Recently, the molecular mechanisms underlying E. sinica
of smoking (one half-pack per day for 50 years) but had ceased
activity have been demonstrated, in vivo, to involve the activation
this habit one year previously. The current medication included
of the slowly activating KCNQ1 potassium channel and other
methylprednisolone (2 mg/day) and the β2-agonist fenoterol (2.5
members of the KCNE protein family.9 Although this activation
mg/day). The patient reported no history of alcohol or
could be expected to precipitate ventricular arrhythmia, further
intravenous drug abuse, and had no remarkable family history of
investigation is required to confirm this. Nonetheless, because
cardiovascular disease or sudden cardiac death. He reported
even short-term, low-dose intake of E. sinica is associated with the
taking herbal medicine containing E. sinica over the course of two
risk of life-threatening ventricular arrhythmias, its use should be
days (total four doses) for abdominal discomfort and indigestion.
closely monitored and tightly regulated.
I concluded that the consumption of the herbal medicine was the
cause of the VT with two distinct QRS morphologies.
References
The patient was prescribed clopidogrel, warfarin, an
angiotensin-converting enzyme inhibitor, a β-blocker, and a statin,
1) Dulloo AG. Herbal simulation of ephedrine and caffein in
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treatment of obesity. Int J Obes Relat metab Disord. 2002;26:590-
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592.
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2) Haller CA, Benowitz NL. Adverse cardiovascular and central
nervous system events associated with dietary supplements
Discussion
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