Pilsicainide Toxicity-Induced Brugada-Like ST Segment Elevation and Increased Pacing Voltage Threshold

Pilsicainide is a class Ic antiarrhythmic agent that exhibits fully selective sodium channel blockade. In Japan, it is one of the most prescribed medicines for rhythm control in atrial fibrillation. Pilsicainide is mainly excreted by the kidney. Therefore, the plasma concentration of pilsicainide is likely to be increased in patients with renal insufficiency. In this case report, a 90-year-old woman presented with generalized fatigue and loss of appetite. Her ECG showed marked bradycardia and coved-type ST-segment elevation similar to that of the Brugada type 1 pattern. Owing to dehydration, her renal function indices worsened compared with those measured four months prior. The plasma pilsicainide concentration was elevated to 2.67 µg/mL (therapeutic range: 0.20-0.90 µg/mL), indicating pilsicainide toxicity. A transvenous temporary pacemaker was placed; however, the pacing voltage threshold was increased at several sites within the right ventricle. Pilsicainide administration was immediately discontinued. On day 2 of admission, ventricular backup pacing was no longer required, and there was an improvement in renal function and heart failure symptoms, such as pulmonary edema and cardiomegaly. The ECG changes improved alongside the renal function and as the plasma concentration of pilsicainide decreased. In conclusion, elevated plasma concentrations of pilsicainide can induce life-threatening arrhythmias and pacing failure. Therefore, clinicians should prescribe pilsicainide cautiously, particularly in older patients.