A rare case of late-onset ticagrelor-induced sinus arrest

Abstract

Ticagrelor is a potent reversible P2Y12 inhibitor with proven superiority over clopidogrel. Ticagrelor increases the tissue concentration of adenosine, thereby leading to bradyarrhythmia. This complication is reported to occur very early after initiating the drug. A randomized controlled trial reported that ticagrelor-induced pauses have an early onset without much clinical impact. However, our patient developed ticagrelor-induced hemodynamically significant sinus arrest 10 months after coronary artery stenting, which improved after stopping the drug. Ticagrelor should be considered as one of the uncommon reasons for late-onset sinus pause or bradyarrhythmia.

A disproportionality analysis of FDA adverse event reporting system (FAERS) events for ticagrelor

“…Among them, bradycardia is mentioned in the drug labels/datasheets. There are multiple case reports about bradycardia-related ADEs caused by ticagrelor and serious bradyarrhythmia, both as early effects or in a delayed fashion ( Al-Bayati et al, 2021 ; Aranganathan et al, 2021 ; Kotaru and Kalavakunta, 2021 ). The EMA identified ticagrelor-related bradyarrhythmia as a potential safety issue and included it in the European Risk Management Plan in 2011 ( Pujade et al, 2020 ).…”

“…Furthermore, new safety information about central sleep apnea (CSA) and Cheyne-Stokes respiration was added in September 2020, and a new section about CSA and Cheyne-Stokes respiration was added to the “WARNINGS AND PRECAUTIONS” section in August 2021 ( FDA, 2020 ; FDA, 2021 ). Over the past years, several case reports have emerged showing the possibility of serious ticagrelor-induced bradyarrhythmia ( Al-Bayati et al, 2021 ; Aranganathan et al, 2021 ; Kotaru and Kalavakunta, 2021 ). A sub-study of the PLATO trial showed that more patients treated with ticagrelor had ventricular pauses compared to clopidogrel-treated patients, but there were no apparent clinical consequences related to the increase in ventricular pauses in patients receiving ticagrelor ( Scirica et al, 2011 ).…”