Cardiac Episodes in Patient on Multiple Medications: Evaluating Potential Drug Interactions and QT Prolongation

Case at a Glance

A 35-year-old transgender female presents with recurrent episodes of chest pain, palpitations, and hypertensive crises over 2 months, raising concerns about potential medication interactions and QT prolongation syndrome.

Patient's Story

The patient is a 35-year-old transgender female, height 5'9", weight 130 pounds, with a history of smoking and degenerative cervical spine disease. She takes spironolactone, estradiol, progesterone, and citalopram as part of her hormone therapy and mental health management. Over the past 2 months, she has experienced multiple episodes resembling cardiac events, characterized by severe chest pain, panic-like symptoms, dizziness, coordination problems, and feelings of impending doom. These episodes often occur after taking her medications and have been exacerbated by energy drink consumption. During acute episodes, her blood pressure spikes dramatically to 167 mmHg and potentially higher (>180 mmHg), though it typically normalizes by the time she reaches the emergency department.

Initial Assessment

The patient has made multiple emergency department visits with complaints of chest pain and palpitations. During these visits, her vital signs typically show normalized blood pressure and normal electrocardiograms, making diagnosis challenging. Her baseline blood pressure is usually within normal limits. She reports a recent decrease in caffeine tolerance coinciding with the onset of symptoms.

The Diagnostic Journey

The patient began researching her symptoms and discovered potential connections between her medications, particularly focusing on citalopram's association with QT prolongation and torsades de pointes. She identified a temporal relationship between medication administration and symptom onset, as well as an apparent interaction between citalopram and energy drink consumption that she had not previously experienced. The intermittent nature of symptoms and their resolution by the time of medical evaluation has made diagnosis elusive.

Final Diagnosis

Suspected medication-induced QT prolongation with possible torsades de pointes, complicated by caffeine-drug interactions and potential medication timing issues. Differential diagnosis includes panic disorder exacerbated by physiological changes from drug interactions.

Treatment Plan

1. Immediate cardiac monitoring with 12-lead ECG and QTc interval measurement
2. Comprehensive medication review and interaction analysis
3. Gradual reduction or elimination of energy drink consumption
4. Consideration of alternative SSRI with lower QT prolongation risk
5. Electrolyte panel including magnesium, potassium, and calcium levels
6. 24-hour Holter monitor to capture arrhythmic episodes
7. Endocrinology consultation for optimization of hormone therapy
8. Patient education regarding drug-caffeine interactions

Outcome and Follow-up

Patient requires close cardiovascular monitoring and medication adjustment. Follow-up includes serial ECGs, electrolyte monitoring, and coordination between cardiology, endocrinology, and psychiatry services. Smoking cessation counseling is recommended as an additional cardiac risk reduction measure. Long-term management focuses on maintaining effective hormone therapy and mental health treatment while minimizing cardiac risks.