What is the appropriate management for a 16-year-old female with tachycardia, dizziness, chest pain, and abnormal labs, including elevated ferritin and thrombocytosis, while taking tri-lo-milli (ethinyl estradiol and levonorgestrel)?

Management of a 16-Year-Old Female with Tachycardia, Dizziness, and Abnormal Labs on Oral Contraceptives

Discontinue tri-lo-milli (ethinyl estradiol/levonorgestrel) immediately, as this patient's presentation is highly concerning for drug-induced arrhythmia or a prothrombotic complication from estrogen-containing oral contraceptives. 1

Immediate Actions

Discontinue Offending Medication

• Withdrawal of tri-lo-milli is the first priority, as the ESC guidelines mandate that when drug-induced arrhythmias are suspected, any offending agent must be interrupted immediately (Class I recommendation, Level B evidence). 1
• Ethinyl estradiol-containing oral contraceptives are known to induce prothrombotic states and can alter cardiac electrical properties, particularly in susceptible individuals. 2, 3

Emergency Department Evaluation Required

• This patient requires immediate emergency department referral given the constellation of tachycardia with positional changes (suggesting possible postural orthostatic tachycardia syndrome or arrhythmia), substernal chest pain, and systemic symptoms. 4
• The positional heart rate increase is particularly concerning and warrants continuous cardiac monitoring. 4

Comprehensive Cardiac Workup

Essential Diagnostic Tests

• 12-lead ECG to evaluate for QT prolongation (drug-induced), pre-excitation patterns, conduction abnormalities, or evidence of structural heart disease. 4, 5
• 24-48 hour Holter monitor to capture arrhythmic episodes, particularly given the episodic nature of symptoms with positional changes. 4
• Echocardiogram to rule out structural heart disease, including cardiomyopathy, valvular abnormalities, or ventricular dysfunction. 4, 5
• Continuous telemetry monitoring during the initial evaluation period to assess for sustained or paroxysmal arrhythmias. 1

Laboratory Assessment

• Electrolyte panel (potassium, magnesium, calcium) as electrolyte abnormalities can contribute to arrhythmias and may be exacerbated by oral contraceptives. 1
• Thyroid function tests (TSH, free T4) to exclude hyperthyroidism, which occurs in 10-25% of patients with arrhythmias and can present with similar symptoms. 5
• Troponin to evaluate for myocardial injury given the substernal chest pain. 1
• D-dimer and consider CT pulmonary angiography if there is clinical suspicion for pulmonary embolism, as estrogen-containing contraceptives significantly increase VTE risk, particularly in the first few months of use. 2

Interpretation of Current Laboratory Findings

Elevated Ferritin with Normal Iron Studies

• The elevated ferritin (474) with normal iron, iron saturation, and TIBC suggests ferritin is acting as an acute phase reactant rather than indicating iron overload.
• This pattern indicates an inflammatory or stress response, which could be related to an underlying thrombotic process, infection, or systemic inflammation. 2
• Thrombocytosis (platelet count 474) further supports an inflammatory or prothrombotic state, which is consistent with estrogen-induced hypercoagulability. 6, 2

Mildly Elevated Platelets

• The platelet count of 474 represents mild thrombocytosis, which combined with estrogen use raises concern for increased thrombotic risk. 6
• This finding, along with the elevated ferritin, suggests the patient may be in a prothrombotic state. 2

Specific Arrhythmia Management

If Hemodynamically Unstable

• Immediate electrical cardioversion is indicated if the patient develops hemodynamic instability (hypotension, altered mental status, severe chest pain, or syncope). 1, 5
• This takes priority over all pharmacological interventions. 5

If Hemodynamically Stable with Documented Arrhythmia

• For supraventricular tachycardia: Attempt vagal maneuvers first, followed by IV adenosine 6 mg rapid push if unsuccessful, then IV metoprolol if adenosine fails. 4, 5
• Beta-blockers (cardioselective such as metoprolol) are first-line for prophylaxis if recurrent arrhythmias are documented. 1, 4
• Avoid AV nodal blocking agents if pre-excitation is present on ECG. 4

Risk Stratification for Thrombotic Events

High-Risk Features Present

• Estrogen-containing oral contraceptive use is the most significant modifiable risk factor, as ethinyl estradiol increases VTE risk through prothrombotic effects on hemostatic pathways. 2, 3
• The risk is highest in the first few months of use, and this patient's two-week symptom duration fits this timeline. 2
• Substernal chest pain with tachycardia raises concern for pulmonary embolism or coronary vasospasm (rare but reported with estrogen). 1

Evaluation for VTE

• Given the combination of chest pain, tachycardia, nausea, and prothrombotic laboratory findings, pulmonary embolism must be excluded with appropriate imaging if clinical suspicion is moderate to high. 2

Alternative Contraception Counseling

After Acute Management

• Do not restart ethinyl estradiol-containing contraceptives in this patient given her adverse reaction. 1
• Consider progestin-only methods (IUD, implant, or pills) as alternatives, which do not carry the same thrombotic or arrhythmic risks. 2
• If combined hormonal contraception is desired in the future, estradiol-based formulations (E2/NOMAC or E2V/DNG) have significantly less haemostatic impact than ethinyl estradiol formulations, though given this patient's presentation, progestin-only methods are safer. 3

Common Pitfalls to Avoid

• Do not attribute symptoms solely to anxiety or benign palpitations without comprehensive cardiac evaluation, as this patient has objective tachycardia with positional changes and concerning associated symptoms. 4
• Do not restart oral contraceptives until the underlying cause of symptoms is identified and resolved. 1
• Do not delay emergency evaluation if symptoms recur or worsen, particularly if syncope, severe chest pain, or dyspnea develop. 4, 5
• Do not overlook the temporal relationship between medication initiation and symptom onset when evaluating for drug-induced arrhythmias. 1

Follow-Up After Acute Phase

• Repeat evaluation if symptoms persist after discontinuation of oral contraceptives, as this would suggest an underlying cardiac substrate rather than pure drug effect. 1
• Consider genetic testing for inherited arrhythmia syndromes (long QT, Brugada) if arrhythmias persist off medication or if there is family history of sudden cardiac death. 1
• Monitor for resolution of thrombocytosis and ferritin elevation after discontinuation of oral contraceptives to confirm these were reactive changes. 6