Transcranial magnetic stimulation as an antidepressant alternative in a patient with Brugada syndrome and recurrent syncope

Mayo Clin Proc. 2014 Nov;89(11):1584-7. doi: 10.1016/j.mayocp.2014.08.010. Epub 2014 Nov 3.

Abstract

Brugada syndrome (BrS) is a common occult cause of sudden cardiac arrest in otherwise healthy-appearing adults. The pathognomonic electrocardiographic pattern may be unmasked only by certain medications, many of which are unknown. We report a case of a depressed but otherwise healthy man with an asymptomatic right bundle branch block on electrocardiography who experienced antidepressant-induced BrS and ultimately recovered with transcranial magnetic stimulation (TMS). After an initial trial of nortriptyline, the patient's depressive symptoms improved; however, he experienced a syncopal event and was subsequently diagnosed as having BrS. Cross titration to bupropion, which had not previously been known to exacerbate BrS, was followed by another cardiac event. As a result, the patient was referred for TMS as a substitute for pharmacotherapy. After 31 TMS sessions over 8 weeks, the patient demonstrated significant improvement by subjective report and objective reduction in his Patient Health Questionnaire-9 scores from 10 (moderate) to 1 (minimal). Transcranial magnetic stimulation is a Food and Drug Administration-approved nonpharmacologic treatment for depression. Given the potential lethality of BrS with known and unknown psychopharmacologic agents, providers should consider TMS as first-line therapy in this patient population. Bupropion should be added to the list of agents known to exacerbate this disease.

Publication types

  • Case Reports

MeSH terms

  • Adult
  • Antidepressive Agents, Second-Generation / adverse effects
  • Antidepressive Agents, Second-Generation / therapeutic use
  • Antidepressive Agents, Tricyclic / adverse effects
  • Antidepressive Agents, Tricyclic / therapeutic use
  • Brugada Syndrome / chemically induced*
  • Brugada Syndrome / diagnosis
  • Brugada Syndrome / genetics
  • Bupropion / adverse effects
  • Bupropion / therapeutic use*
  • Comorbidity
  • Depressive Disorder, Major / drug therapy
  • Depressive Disorder, Major / genetics
  • Depressive Disorder, Major / therapy*
  • Drug Therapy, Combination
  • Electrocardiography / drug effects*
  • Humans
  • Male
  • Mianserin / adverse effects
  • Mianserin / analogs & derivatives*
  • Mianserin / therapeutic use
  • Mirtazapine
  • NAV1.5 Voltage-Gated Sodium Channel / genetics
  • Nortriptyline / adverse effects*
  • Nortriptyline / therapeutic use
  • Syncope / chemically induced
  • Transcranial Magnetic Stimulation / methods*

Substances

  • Antidepressive Agents, Second-Generation
  • Antidepressive Agents, Tricyclic
  • NAV1.5 Voltage-Gated Sodium Channel
  • SCN5A protein, human
  • Bupropion
  • Mianserin
  • Mirtazapine
  • Nortriptyline