Severe bradycardia and syncope due to topical ophthalmic timolol
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0-year-old male patient presented to our emergency room complaining of dizziness and syncope. His medical history included mitral valve replacement 5 years previously, atrial fibrillation for 4 years, and glaucoma for 10 days. Medication consisted of warfarin (5 mg/day; for 5 years) and latanoprost/timolol 50 mcg/ ml+5 mg/ml eye drops (Xalacom®, Pfizer, Belgium) once for each eye for 10 days. He had no history of taking digoxin or other atrioventricular node-blocking agents and herbal agents. Examination revealed a blood pressure of 85/50 mmHg, a pulse of 30 bpm, and a metallic heart sound at the apex; the other systemic findings were un-
Fig. 1 7 Electrocardiogram showing atrial fibrillation with low ventricular rate (35 bpm) on admission to the emergency room
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Herz 5 · 2013
U. Canpolat · K.M. Gürses · K. Aytemir · A. Oto Faculty of Medicine, Department of Cardiology, Hacettepe University, Sihhiye, Ankara
Severe bradycardia and syncope due to topical ophthalmic timolol remarkable. Electrocardiography on admission demonstrated atrial fibrillation with a low atrial rate (35 bpm) (. Fig. 1). Previous ECG records at regular checkup visits revealed atrial fibrillation with a normal ventricular rate approximately between 85 and 95 bpm. The patient’s latest ECG had been recorded was 1 month earlier (. Fig. 2) Echocardiography showed normal left ventricular systolic function, a normal mitral prosthetic valve, and a dilated left atrium (61 mm). Because of the hemodynamic instability of the patient, temporary transvenous pacemaker implantation was performed through the jugular venous approach and ECG re-
vealed a ventricular pacemaker rhythm of 60 bpm (. Fig. 3). Afterwards, the patient’s hemodynamics improved and he was asymptomatic. Use of the ophthalmic solution timolol was discontinued. He was hospitalized for 5 days to observe the underlying rhythm. There was persistence of atrial fibrillation with a low ventricular response during the hospital stay. Therefore, permanent pacemaker implantation (VVI) was performed successfully with no complications. The remaining hospital stay was uneventful. The patient was asymptomatic at the 1-month and 6-month follow-up visits, and a checkup of the pacemaker revealed 89% right
Fig. 2 9 Previous ECG at a check-up visit (1 month earlier) showed atrial fibrillation with a ventricular rate of 90 bpm
Fig. 3 9 ECG showing the pacemaker rhythm (60 bpm)
ventricular pacing with a baseline rate of 60 bpm. Timolol maleate is a nonselective β-adrenoceptor antagonist currently used mainly as an ocular preparation for the treatment of glaucoma and ocular hypertension. Despite the topical administration, ophthalmic timolol causes systemic adrenergic β-blocking because of absorption from the eye into the systemic circulation [1]. It can cause atrioventricular block and bradycardia. Although most of the cardiovascular complications such as bradyarrhythmia and atrioventricular blocks are reversible, there may be permanent bradycardia and requirement for pacemaker implantation [2, 3]. Be
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