Reflex Supraventricular Tachycardia and Chest Pain Following the First Dose of Fixed-Dose Perindopril/Amlodipine in an Older Patient with Hypertension and Type 2 Diabetes Mellitus: A Case Report

Background: Fixed-dose combinations (FDCs) of an angiotensin-converting enzyme (ACE) inhibitor and a dihydropyridine calcium-channel blocker (CCB) are recommended as initial therapy for most patients with arterial hypertension and are generally well tolerated. Reflex tachycardia has not previously been reported with the perindopril/amlodipine combination. Case Presentation: A 70-year-old Caucasian man with arterial hypertension and type 2 diabetes mellitus developed chest pain 1 hour after the first dose of AlmirinComb 4/5 mg (perindopril 4 mg/amlodipine 5 mg). The prehospital ECG showed supraventricular tachycardia (SVT), which was terminated with adenosine (6 mg, then 12 mg); conversion to sinus rhythm was accompanied by transient inferior ST denivelation, and the chest pain resolved immediately. On arrival at the hospital, he was pain-free, haemodynamically stable (blood pressure 162/90 mmHg, heart rate 82 beats/min), and in normal sinus rhythm without ST-segment changes; serial high-sensitivity troponin I values remained within the normal range. Cardiology consultation attributed the event to reflex tachycardia. According to the World Health Organization-Uppsala Monitoring Centre (WHO-UMC) causality assessment system, the reaction was classified as probable. He was discharged on nebivolol with scheduled ambulatory follow-up (Holter-ECG, exercise testing, and echocardiography). Conclusion: This case suggests that a first dose of an ACE inhibitor/dihydropyridine FDC may rarely trigger a reflex-mediated supraventricular tachyarrhythmia with chest pain in an older patient at high cardiovascular risk. Blood pressure and heart rate monitoring after the first dose, patient education regarding symptoms, and prompt pharmacovigilance reporting are advisable.