Cholestasis due to biliary obstruction can cause cardiogenic shock with bradycardia by delaying the elimination of arotinolol.

Abstract

Cardiogenic shock with bradycardia due to beta-blockers is well-documented; however, this condition in association with arotinolol is unreported. We present a case of cardiogenic shock resulting from delayed arotinolol clearance caused by bile duct obstruction. A man in his 60s presented to our hospital with jaundice. We suspected acute obstructive suppurative cholangitis; however, the patient did not exhibit fever or abdominal symptoms. Based on the physical examination results, we concluded the patient was in cardiogenic shock as a consequence of delayed arotinolol elimination. We attempted to maintain organ perfusion using norepinephrine and dopamine, with minimal response. On initiating isoproterenol, the heart rate stabilised. After tapering off isoproterenol, endoscopic retrograde cholangiopancreatography (ERCP) was performed. Subsequent serum arotinolol level measurement revealed a significant reduction in the elimination half-life before and after ERCP. In cases of cardiogenic shock associated with arotinolol, presumably eliminated via the bile duct, it is crucial to consider potential delayed elimination and to appropriately time ERCP.