Accelerated AV nodal conduction with use of procainamide in atrial fibrillation

Area of Science:

• Cardiology
• Emergency Medicine
• Clinical Pharmacology

Background:

• Atrial fibrillation is a frequent emergency department dysrhythmia.
• Chemical or electrical cardioversion is indicated for recent-onset atrial fibrillation (<48h) in low-risk patients.
• Intravenous procainamide is often considered for acute atrial fibrillation due to efficacy and safety.

Observation:

• A case of lone paroxysmal atrial fibrillation in a patient with a structurally normal heart is presented.
• The patient experienced an adverse reaction to intravenous procainamide during chemical cardioversion.
• The adverse reaction manifested as paradoxical accelerated atrioventricular nodal conduction and secondary hypotension.

Findings:

• Intravenous procainamide administration led to an unexpected adverse event in a hemodynamically stable patient.
• The patient developed accelerated atrioventricular nodal conduction and subsequent hypotension.
• This case highlights a rare but significant complication of procainamide use.

Implications:

• Clinicians should maintain a low threshold for administering a rate-controlling agent alongside procainamide.
• Immediate availability of electrical cardioversion facilities is essential when using procainamide for cardioversion.
• This case underscores the importance of vigilant monitoring for adverse reactions during chemical cardioversion.