Oxymetazoline-associated refractory atrial fibrillation

Introduction: Oxymetazoline is a widely used over-the-counter topical nasal decongestant that is generally perceived as safe. Although systemic cardiovascular adverse effects have been reported, clinically significant arrhythmias remain rare. Case description: A 64-year-old man with diabetes and hypertension developed new-onset atrial fibrillation with a rapid ventricular response up to 180 bpm. This arrhythmia was refractory to pharmacological and synchronized electrical cardioversion, necessitating intensive care unit admission for refractory arrhythmia and hypoxic respiratory failure. Further history revealed oxymetazoline nasal spray use for several days prior to presentation. Following discontinuation of oxymetazoline, sustained conversion to sinus rhythm occurred and was maintained at 6-month follow-up. Discussion: This case underscores the potential for serious cardiovascular effects of topical nasal decongestants that may be underrecognized because of their over-the-counter availability. While atrial fibrillation has been reported with other imidazoline-containing nasal decongestants, oxymetazoline-associated atrial fibrillation refractory to standard pharmacologic and electrical cardioversion requiring intensive care unit admission has not been previously reported, to our knowledge. Conclusion: This case highlights a rare but potentially severe arrhythmogenic complication of oxymetazoline nasal spray. Clinicians should consider over-the-counter topical medications as potential contributors in patients presenting with unexplained or refractory atrial fibrillation.