What medications can cause presyncope with tachycardia?

From the Guidelines

Drugs that can cause pre-syncope tachycardia include stimulants, antidepressants, antipsychotics, beta-agonist bronchodilators, thyroid medications, vasodilators, anticholinergics, and certain antibiotics and antiarrhythmics, as reported in 1 and 1.

Common Culprits

• Stimulants such as caffeine, pseudoephedrine, and amphetamines, which directly increase heart rate through sympathetic nervous system activation
• Antidepressants, particularly tricyclics like amitriptyline and SSRIs like fluoxetine, can cause tachycardia through anticholinergic effects or serotonin modulation
• Antipsychotics such as quetiapine and olanzapine may induce orthostatic hypotension with reflex tachycardia
• Beta-agonist bronchodilators like albuterol and salmeterol commonly cause heart racing as a side effect, as noted in 1

Other Contributing Factors

• Thyroid medications like levothyroxine can cause tachycardia if dosed too high
• Vasodilators including nitroglycerin, hydralazine, and calcium channel blockers may cause reflex tachycardia as blood pressure drops
• Anticholinergics such as atropine and scopolamine directly increase heart rate by blocking parasympathetic influence
• Certain antibiotics (fluoroquinolones like ciprofloxacin) and antiarrhythmics (particularly Class IA drugs like quinidine) can prolong QT interval and trigger dangerous arrhythmias, as discussed in 1

Key Considerations

• Patients experiencing pre-syncope tachycardia should seek medical attention promptly, as dose adjustments or medication changes may be necessary
• The risk-benefit analysis of using these medications should be carefully evaluated, taking into account the individual patient's condition and medical history, as emphasized in 1

From the FDA Drug Label

1. 3 Increased Blood Pressure and Heart Rate CNS stimulants cause an increase in blood pressure (mean increase approximately 2 to 4 mmHg) and heart rate (mean increase approximately 3 to 6 bpm). Some patients may have larger increases. Monitor all methylphenidate hydrochloride-treated patients for hypertension and tachycardia.

Drugs that can cause pre-syncope tachycardia include:

• Methylphenidate: due to its effects on increasing blood pressure and heart rate, which can lead to tachycardia and potentially pre-syncope.
• Amphetamine: as a CNS stimulant, it can also increase blood pressure and heart rate, potentially causing tachycardia and pre-syncope.

Key points to consider:

• Monitoring: patients treated with these medications should be monitored for hypertension and tachycardia.
• Increased risk: patients with pre-existing cardiac conditions may be at higher risk for adverse effects. 2 3

From the Research

Drugs that can cause Pre-Syncope Tachycardia

• The study 4 found that 12 medications were implicated in causing syncope and presyncope, although it does not specifically mention which drugs can cause pre-syncope tachycardia.
• Pseudoephedrine, a drug with central nervous system stimulant properties, can cause increased heart rate and blood pressure, which may lead to pre-syncope tachycardia 5.
• Amphetamines and methylphenidate, which are psychostimulants, can increase central dopamine and norepinephrine activity, leading to increased heart rate and blood pressure, potentially causing pre-syncope tachycardia 6.
• Prescription psychostimulants, including amphetamines, have been found to be effective in treating stimulant use disorder, but may also cause increased heart rate and blood pressure, potentially leading to pre-syncope tachycardia 7.

Mechanisms of Action

• Amphetamine and methylphenidate increase central dopamine and norepinephrine activity, which can lead to increased heart rate and blood pressure 6.
• Pseudoephedrine has central nervous system stimulant properties, which can cause increased heart rate and blood pressure 5.
• Prescription psychostimulants, including amphetamines, can increase heart rate and blood pressure, potentially leading to pre-syncope tachycardia 7.

Patient Populations at Risk

• Elderly patients and those taking multiple medications may be at increased risk of syncope and presyncope due to adverse drug reactions 4.
• Patients with a history of substance use disorder, particularly those with cocaine use disorder, may be at increased risk of pre-syncope tachycardia due to the use of prescription psychostimulants 7.