From the FDA Drug Label
Patients with cardiovascular disease should be given nortriptyline hydrochloride only under close supervision because of the tendency of the drug to produce sinus tachycardia and to prolong the conduction time. Myocardial infarction, arrhythmia, and strokes have occurred
The workup for a 40-year-old female with sudden onset of palpitations and shortness of breath (SOB) after using Aventyl (nortriptyline) for migraines should include a cardiovascular evaluation due to the potential of nortriptyline to produce sinus tachycardia and prolong conduction time, which may lead to serious cardiac events such as myocardial infarction, arrhythmia, and strokes 1.
- Key considerations in the workup include:
- Monitoring for signs of cardiac complications
- Assessing the patient's cardiovascular history
- Evaluating the patient's current symptoms and their potential relation to nortriptyline use
- Considering alternative treatments for migraines if necessary, given the potential risks associated with nortriptyline in patients with cardiovascular disease.
From the Research
The workup for a 40-year-old female experiencing sudden palpitations and shortness of breath after using nortriptyline should begin with immediate discontinuation of the medication and prompt medical evaluation. Initial assessment should include vital signs (particularly heart rate and blood pressure), oxygen saturation, and a 12-lead ECG to evaluate for tricyclic antidepressant-induced cardiac toxicity, including QT prolongation, tachyarrhythmias, or conduction abnormalities 2. Laboratory tests should include complete blood count, comprehensive metabolic panel, thyroid function tests, and serum nortriptyline levels. Additional cardiac workup may include continuous cardiac monitoring, echocardiogram to assess cardiac function, and possibly exercise stress testing. These symptoms likely represent nortriptyline's anticholinergic and cardiovascular side effects, as tricyclic antidepressants can block sodium channels and interfere with cardiac conduction.
After acute management, alternative migraine prophylaxis options should be considered, such as:
- Topiramate (starting at 25mg daily, gradually increasing to 50-100mg twice daily)
- Propranolol (40-160mg daily)
- Newer CGRP antagonists like erenumab (70-140mg monthly) 3. The patient should be monitored for resolution of symptoms after medication discontinuation and evaluated for any underlying cardiac conditions that may have been exacerbated by nortriptyline. It is also essential to consider the patient's treatment needs, taking into account the attack severity, presence of associated symptoms, and the degree of migraine-related disability when choosing an alternative treatment option 4, 5.