Sensation of Lump in Throat in Atrial Flutter Patients on Rate-Control Medications
The sensation of a lump in the throat (globus sensation) in a patient with atrial flutter taking beta-blockers, diltiazem, or verapamil is not a recognized adverse effect of these medications and should prompt evaluation for alternative causes including gastroesophageal reflux, thyroid pathology, or anxiety disorders.
Medication Safety Profile for Rate-Control Agents
The commonly used rate-control medications for atrial flutter have well-established adverse effect profiles that do not include globus sensation:
Beta-Blockers
- Common adverse effects include: hypotension, worsening heart failure, bronchospasm, and bradycardia 1
- Contraindications: AV block greater than first degree, SA node dysfunction without pacemaker, decompensated systolic heart failure, hypotension, cardiogenic shock, and reactive airway disease 1
- No documented association with throat symptoms or globus sensation
Diltiazem
- Common adverse effects include: hypotension, worsening heart failure in patients with pre-existing ventricular dysfunction, bradycardia, and abnormal liver function studies 1
- Cardiac conduction effects: prolongs AV node refractory periods and may rarely result in abnormally slow heart rates or second- or third-degree AV block 2
- Critical warning: acute hepatic injury has been noted in rare instances with significant elevations in alkaline phosphatase, LDH, SGOT, and SGPT 2
- No documented association with throat or esophageal symptoms
Verapamil
- Common adverse effects include: negative inotropic effects with potential for congestive heart failure (1.8% incidence in clinical trials), hypotension (2.5% incidence), and elevated liver enzymes 3
- Serious cardiac effects: can cause asymptomatic first-degree AV block and transient bradycardia, with higher degrees of AV block occurring infrequently (0.8%) 3
- Contraindicated in: severe left ventricular dysfunction (ejection fraction <30%), moderate to severe heart failure symptoms, and Wolff-Parkinson-White syndrome with atrial fibrillation/flutter 3
- No documented association with globus sensation or throat symptoms
Clinical Approach to Globus Sensation
Since these rate-control medications do not cause throat symptoms, evaluate for:
Primary Differential Diagnoses
- Gastroesophageal reflux disease (GERD): most common cause of globus sensation, particularly relevant as calcium channel blockers can theoretically worsen reflux by reducing lower esophageal sphincter tone
- Thyroid pathology: thyroid nodules, goiter, or thyroiditis requiring neck examination and thyroid function testing
- Anxiety and stress-related disorders: functional globus sensation
- Pharyngeal or laryngeal pathology: requiring direct visualization if symptoms persist
Drug Interaction Considerations
- Verapamil and diltiazem are CYP3A4 substrates and moderate CYP3A4 inhibitors 3, which can affect metabolism of other medications the patient may be taking
- Review complete medication list for drugs that could cause esophageal irritation or dysphagia
- Consider if patient is taking medications that prolong QT interval in combination with these rate-control agents, as this increases risk of torsades de pointes 4
Important Clinical Caveats
The combination of beta-blockers with calcium channel blockers (diltiazem or verapamil) carries significant risk and should be used only with caution and close monitoring due to additive negative effects on heart rate, AV conduction, and cardiac contractility, with reports of excessive bradycardia and complete heart block 3. This combination may be contributing to symptoms if the patient experiences significant bradycardia causing anxiety or altered sensation.
AV block related to these medications is commonly "related to drugs" but rarely "caused by drugs" - only 15% of patients with AV block during therapy with beta-blockers, verapamil, or diltiazem have block truly caused by the medication, and 56% of those who improve after drug discontinuation experience recurrence without therapy 5.