Bradyarrhythmias secondary to topical levobunolol hydrochloride solution

Abstract

An 88-year-old man was admitted with fatigue, dizziness, and heart palpitations. Both the electrocardiogram and Holter confirmed the existence of sinus bradycardia and sinus arrest. One hour prior to the onset of symptoms, he received levobunolol hydrochloride solution topically. The levobunolol hydrochloride solution was discontinued and the bradycardia resolved. He was diagnosed as having intermittent sinus bradycardia and sinus arrest, induced by topical β-blocker therapy. Levobunolol hydrochloride solution is an effective therapy for ocular hypertension, probably by reducing aqueous fluid production. However, it can induce cardiac side effects such as bradyarrhythmia and should be used with caution in elderly patients or patients with cardiac disease.

Keywords: bradycardia; glaucoma; the elderly; topical β-blocker.

Figure 1

ECG results. Notes: The ECG showed sinus bradycardia, AVB (A) and sinus arrest (B). The symptomatic bradycardia was observed almost 1 hour after the instillation of levobunolol hydrochloride solution (indicated by red arrows) (C). The red boxes refer to the occurrence of bradycardia. Abbreviations: ECG, electrocardiogram; AVB, atrioventricular conduction block; HR, heart rate; RR, R-R interval; min, minimum; max, maximum; bpm, beats per minute; H, hour; M, minute.

Figure 2

The recovery of heart rhythm shown by ECG. Notes: ECG demonstrated the recovery of sinus rhythm (A) after withdrawal of levobunolol hydrochloride solution compared to the drug-induced bradycardia (B). Abbreviation: ECG, electrocardiogram.

Figure 3

Holter results. Notes: Holter recorded the minimum heart rate at 25 bpm with a long R–R interval of 3.5 seconds at 9:59 am, about 2 hours after the instillation of levobunolol hydrochloride solution (A). After 48 hours of withdrawal of levobunolol, Holter showed no obvious sinus arrest and the minimum heart rate was 37 bpm (B). Abbreviation: bpm, beats per minute.