Introduction

Ginseng has been revered as a traditional medicinal herb in Asia for millennia, with its discovery reportedly dating back 5,000 years in the mountains of Manchuria [1]. The active components, known as ginsenosides, are triterpenoid glycosides (saponins) [2] that exhibit antioxidant and neuromodulatory properties. These compounds are credited with health benefits across a broad spectrum of conditions, from metabolic syndrome [3] to cancer treatment [4]. However, misuse of ginseng can lead to adverse effects, including potentially life-threatening unstable arrhythmias. While these risks are rare when ginseng is used at recommended dosages, they likely pose a threat in regions where its consumption is random and excessive. This case report highlights an instance of ventricular tachycardia with a prolonged QT interval in a woman who regularly consumed raw ginseng root.

She was promptly transferred to the intensive cardiac care unit, and while being assessed, she developed a sustained pulseless monomorphic VT with altered sensorium. A 200J direct current shock promptly restored sinus rhythm, and the subsequent ECG indicated a significantly prolonged QT interval (QTc—560 to 580 ms, Bazett formula) (Figure 2). An intravenous magnesium sulfate injection (2 g) was administered at this stage.

Figure 2. Markedly prolonged QT interval (QTc—560 to 580 ms, Bazett formula) recorded on the ECG that was taken soon after cardioversion of VT.

Blood tests revealed a serum potassium level of 3 mmol/l, while all other parameters, including arterial blood gases, were normal. Intravenous potassium correction was initiated, and a beta blocker (Metoprolol succinate 25 mg once daily) was added to her treatment plan. With these measures, there was no recurrence of VT. A bedside echocardiogram revealed a structurally normal heart. She had an uneventful recovery, and by the third day, her QT interval had normalized to a corrected QT of 436 ms (Figure 3).

Figure 3. Normal QT interval on day 3 of admission (QTc - 436 ms).

The patient disclosed that she had been consuming a crushed ginseng root (Figure 4) mixture with water twice a day as a traditional remedy for hemorrhoids. She had been doing this intermittently for 2 months, but recently increased her intake to larger quantities (5-8 g of raw dried ginseng root daily). She was on absolute fasting (abstaining from both solid and liquid food intake) for 2 days before the cardiac emergency occurred, during which she continued to take the ginseng mixture. She is a mother of three and reported no significant family or past medical history. She was not on any other medication, and there was no history to suggest substance abuse.

Figure 4. Dried Ginseng root consumed by the patient.

Discussion

Although ginseng is a well-known medicinal herb, there have been reports of potentially serious cardiac adverse effects. A woman developed long QT with torsades de pointes after consuming ginseng daily for over 6 months [5]. Such adverse reactions are likely rare and considered idiosyncratic. Nonetheless, the effect of ginseng on the QT interval has been demonstrated in a randomized prospective study, where participants taking ginseng extracts for 28 days exhibited a significant prolongation of the QTc compared to the placebo group [6].

In a study involving animal subjects, the infusion of Rg1 ginsenosides (the bioactive component of ginseng) resulted in the prolongation of the ventricular effective refractory period [7]. Another bioactive component of ginseng, ginsenoside Re, has been shown to suppress the rapid component of the delayed rectifier potassium current (IKr) [8]. This current is crucial for repolarization of the heart muscle cells, and blocking IKr can prolong the ventricular action potential duration, causing delayed repolarization and a prolonged QT interval [9].

The patient also had a low serum potassium level of 3 mmol/l (Normal reference range 3.5 - 5 mmol/l). It is unclear if ginseng directly contributes to hypokalemia, and hence, the association between ginseng intake and reduced potassium levels remains speculative.

Dyselectrolytemia and prolonged QTc during fasting is a well-documented phenomenon [10,11]. In addition to reduced intake during fasting, there is rapid potassium loss through renal excretion [12]. The Volume loss associated with fasting triggers the secretion of aldosterone, which stimulates the reabsorption of sodium and the excretion of potassium, leading to hypokalemia. In addition, metabolic alkalosis observed during fasting leads to bicarbonate diuresis and loss of accompanying potassium ions in the urine [13]. Even though the duration of fasting in this particular case is short (2 days), the possibility that this was a contributing factor to the cardiac arrhythmia cannot be ignored.

Panax pseudoginseng is native to India and is particularly abundant in the Northeast. Despite its presence in various parts of the region, its survival is threatened by overexploitation for medicinal use [14]—chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://ijcs.ro/public/IJCS-16-61_Jamir.pdf

Conclusion

Given the widespread use of ginseng, there is a risk of inadvertent misuse leading to potentially life-threatening adverse effects. Clinicians should actively inquire about herbal supplement use in patients with unexplained arrhythmias or QT prolongation. It is also essential to disseminate information about such adverse effects to the public.

References

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