title: Transcranial magnetic stimulation as an antidepressant alternative in a patient with Brugada syndrome and recurrent syncope.
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.
authors.affiliation: Department of Psychiatry, Walter Reed National Military Medical Center, Bethesda, MD. Electronic address: miguel.m.alampay.mil@health.mil.
authors.forename: Miguel M
authors.initials: MM
authors.lastname: Alampay
authors.affiliation: Department of Medicine-Cardiology, Uniformed Services University of the Health Sciences, Bethesda, MD.
authors.forename: Mark C
authors.initials: MC
authors.lastname: Haigney
authors.affiliation: Department of Cardiology, Fort Belvoir Community Hospital, Fort Belvoir, VA.
authors.forename: Michael C
authors.initials: MC
authors.lastname: Flanagan
authors.affiliation: Department of Psychiatry, Walter Reed National Military Medical Center, Bethesda, MD.
authors.forename: Robert M
authors.initials: RM
authors.lastname: Perito
authors.affiliation: Department of Cardiology, Naval Hospital, Camp Pendleton, CA.
authors.forename: Kathleen M
authors.initials: KM
authors.lastname: Love
authors.affiliation: Department of Research, National Intrepid Center of Excellence, Bethesda, MD.
authors.forename: Geoffrey G
authors.initials: GG
authors.lastname: Grammer
mesh_terms: D000328:Adult; D018687:Antidepressive Agents, Second-Generation / Q000009:adverse effects / Q000627:therapeutic use; D000929:Antidepressive Agents, Tricyclic / Q000009:adverse effects / Q000627:therapeutic use; D053840:Brugada Syndrome / Q000139:chemically induced* / Q000175:diagnosis / Q000235:genetics; D016642:Bupropion / Q000009:adverse effects / Q000627:therapeutic use*; D015897:Comorbidity; D003865:Major Depressive Disorder / Q000188:drug therapy / Q000235:genetics / Q000628:therapy*; D004359:Drug Therapy, Combination; D004562:Electrocardiography / Q000187:drug effects*; D006801:Humans; D008297:Male; D008803:Mianserin / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000627:therapeutic use; D000078785:Mirtazapine; D062554:NAV1.5 Voltage-Gated Sodium Channel / Q000235:genetics; D009661:Nortriptyline / Q000009:adverse effects* / Q000627:therapeutic use; D013575:Syncope / Q000139:chemically induced; D050781:Transcranial Magnetic Stimulation / Q000379:methods*
chemical_list: D018687:Antidepressive Agents, Second-Generation; D000929:Antidepressive Agents, Tricyclic; D062554:NAV1.5 Voltage-Gated Sodium Channel; C568320:SCN5A protein, human; D016642:Bupropion; D008803:Mianserin; D000078785:Mirtazapine; D009661:Nortriptyline