Thanks to Katie for presenting the case of a young man on chronic opioids who presented with diarrhea after running out of medication, followed by episodes of chest pain and shortness of breath and found to have NSVT, likely precipitated by pain and opioid withdrawal! Pearls below:


Top Pearls:

  1. The HEART and TIMI risk scores are the best clinical tools to rule in and rule out ACS (better than any individual clinical finding).
  2. Opioid withdrawal can result in tachycardia and even tachyarrhythmias!
  3. The most common site of origin of recurrent monomorphic VT is the right ventricular outflow tract (RVOT).


For those who want more info:

We briefly mentioned the 2015 JAMA Rational Clinical Examination series systematic review “Does this patient with chest pain have acute coronary syndrome?” in which the individual clinical findings with the highest likelihood ratio for ACS were prior abnormal stress test (LR 3.1), PAD (LR 2.7), and pain radiation to both arms (LR 2.6). However, these findings are not as powerful as ST depression on ECG (LR 5.3), and of course, the HEART and TIMI risk scores (LR 13 and 6.8 respectively). Low range HEART and TIMI scores were also best at ruling out ACS (LR 0.20 and 0.31 respectively).

JAMA. 2015 Nov 10;314(18):1955-65. doi: 10.1001/jama.2015.12735.

Opioid withdrawal symptoms (occur within 6-48 hours of cessation):

  • GI distress (cramps, diarrhea, N/V)
  • Flu-like symptoms (rhinorrhea, diaphoresis, piloerection)
  • Sympathetic arousal (e.g. tachycardia, mydriasis)
  • Other: Yawning, sneezing, dizziness, myalgias, leg cramps

Treatment = methadone, clonidine, diazepam, antiemetics/antidiarrheals

*Pearl: Loperamide, often used to treat diarrhea in opioid withdrawal, is associated with cardiotoxicity in overdose including arrhythmias such as NSVT!

“Frequent” PVCs = 20% of total beats (that’s a lot of PVCs!!). Frequent PVCs may be associated with cardiomyopathy and merit further workup.

NSVT = 3 or more consecutive ventricular beats at >100 bpm with duration <30 sec.

NSVT is common, occurring in up to 4% of the general population.

NSVT Workup: ECG, TTE, and exercise stress testing are generally sufficient to rule out structural heart disease in asymptomatic patients, since prognosis is generally benign. Cardiac MRI or genetic testing may be indicated in symptomatic patients or those with a suggestive family history.

NSVT Treatment: None if asymptomatic and workup is negative. If symptomatic and refractory to withdrawal of known precipitants, beta blockers or calcium channel blockers are 1st line. Ablation or antiarrhythmics are 2nd line treatments; ablation is preferred.

CAST Trial: Caution with class Ic antiarrhythmics (flecainide and propafenone) in patients with CAD due to proarrhythmic effects and increased mortality! Amiodarone and sotalol are effective alternative agents, but there is NO clear evidence that suppressing PVCs with antiarrhythmics improves survival!

*Pearl: The most common site of origin of repetitive monomorphic VT is the right ventricular outflow tract (RVOT).

*Pearl: The prognosis of repetitive monomorphic VT in the absence of structural heart disease is generally good, while structural heart disease and polymorphic VT both carry a worse prognosis.

*Pearl: PVCs have no prognostic relevance outside of acute MI and ischemia!



Have a great day everyone!




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