Is the pepper spray a triggering factor in myocardial infarction? A case report.

Forty-year-old man was admitted to emergency department with complains of chest pain and dispnea after exposure the pepper gas that sprayed to environment during a social event. Physical examination and electrocardiogram was revealed acute myocardial infarction.

Coronary artery aneurysm and thrombosis following chronic ephedra use.

Ephedra, also known as Ma Huang, was commonly used to enhance athletic performance, "fat burning", and weight loss before its removal from the United States in April 2004 due to acute adverse health reactions including lethal arrhythmias, stroke, vasoconstriction, and myocardial infarction. We report the case of a 29-year-old patient with acute myocardial infarction, secondary to coronary artery aneurysms and thrombosis who reported use of Ma Huang, Xenadrine(r)RFA, and Hydroxycut at recommended dosages for a combined total of approximately 2 years. Other causes of coronary artery aneurysm and hypercoagulability were ruled out. Our case exemplifies the long-term (as opposed to acute) danger of ephedrine products and the first case of coronary artery aneurysm associated with its use.

Rivaroxaban versus placebo in patients with acute coronary syndromes (ATLAS ACS-TIMI 46): a randomised, double-blind, phase II trial.

BACKGROUND: Rivaroxaban is an oral direct factor Xa inhibitor that has been effective in prevention of venous thromboembolism in patients undergoing elective orthopaedic surgery. However, its use after acute coronary syndromes has not been investigated. In this setting, we assessed the safety and efficacy of rivaroxaban and aimed to select the most favourable dose and dosing regimen. METHODS: In this double-blind, dose-escalation, phase II study, undertaken at 297 sites in 27 countries, 3491 patients stabilised after an acute coronary syndrome were stratified on the basis of investigator decision to use aspirin only (stratum 1, n=761) or aspirin plus a thienopyridine (stratum 2, n=2730). Participants were randomised within each strata and dose tier with a block randomisation method at 1:1:1 to receive either placebo or rivaroxaban (at doses 5-20 mg) given once daily or the same total daily dose given twice daily. The primary safety endpoint was clinically significant bleeding (TIMI major, TIMI minor, or requiring medical attention); the primary efficacy endpoint was death, myocardial infarction, stroke, or severe recurrent ischaemia requiring revascularisation during 6 months. Safety analyses included all participants who received at least one dose of study drug; efficacy analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00402597. FINDINGS: Three patients in stratum 1 and 26 in stratum 2 never received the study drug. The risk of clinically significant bleeding with rivaroxaban versus placebo increased in a dose-dependent manner (hazard ratios [HRs] 2.21 [95% CI 1.25-3.91] for 5 mg, 3.35 [2.31-4.87] for 10 mg, 3.60 [2.32-5.58] for 15 mg, and 5.06 [3.45-7.42] for 20 mg doses; p<0.0001). Rates of the primary efficacy endpoint were 5.6% (126/2331) for rivaroxaban versus 7.0% (79/1160) for placebo (HR 0.79 [0.60-1.05], p=0.10). Rivaroxaban reduced the main secondary efficacy endpoint of death, myocardial infarction, or stroke compared with placebo (87/2331 [3.9%] vs 62/1160 [5.5%]; HR 0.69, [95% CI 0.50-0.96], p=0.0270). The most common adverse event in both groups was chest pain (248/2309 [10.7%] vs 118/1153 [10.2%]). INTERPRETATION: The use of an oral factor Xa inhibitor in patients stabilised after an acute coronary syndrome increases bleeding in a dose-dependent manner and might reduce major ischaemic outcomes. On the basis of these observations, a phase III study of low-dose rivaroxaban as adjunctive therapy in these patients is underway. FUNDING: Johnson & Johnson Pharmaceutical Research & Development and Bayer Healthcare AG.

Dolor torácico con elevación del segmento ST en un consumidor de cannabis / Chest pain with elevation of the ST segment in a cannabis consumer

La miocarditis se define como una inflamación del miocardio. Frecuentemente se asocia a afectación pericárdica constituyendo una miopericarditis. Su etiología es muy variada, e incluye agentes infecciosos, químicos como drogas de abuso, radiaciones e hipersensibilidad a fármacos. La causa más frecuente es la infección por enterovirus. Es más frecuente en niños, adolescentes y adultos jóvenes, con predominio del sexo masculino. Aunque las manifestaciones clínicas son muy variables, en algunos casos puede semejar un síndrome coronario agudo. Por otro lado, el consumo de cannabis, se ha asociado a vaso espasmo, infarto agudo de miocardio y taquiarrítmias. Se describe el caso de un varón joven, consumidor de cannabis, que consultó por dolor torácico con alteraciones electrocardiográficas y enzimáticas sugestivas de síndrome coronario agudo con elevación del ST. Se discute el diagnóstico diferencial, métodos diagnósticos y actitud terapéutica (AU)

Myocarditis is defined as inflammation of the myocardium, and it is frequently associated with pericardial involvement leading to myopericarditis. Myopericarditis may be due to different etiologies, including infectious and chemical agents, such as drugs of abuse, radiation and hypersensitivity to drugs. Infection caused by enterovirus is the most frequent cause. The disease is more common in children, adolescents and young adults with a predominance of the male sex. Although patients may present different clinical manifestations, in some cases symptoms may resemble an acute coronary syndrome. On the other hand, cannabis consumption has been associated with vasospasm, acute myocardial infarction and tachyarrhythmias. We describe the case of a young man who was a cannabis consumer and presented chest pain with biochemical and electrocardiographic abnormalities suggestive of acute coronary syndrome with an elevated ST segment. The differential diagnosis, diagnostic work-up studies and therapeutic approach are commented on (AU)

Coronary spasm induced by capecitabine mimicks ST elevation myocardial infarction.

Capecitabine is a chemotherapeutic prodrug that is metabolised to 5-fluorouracil. Supported by the National Institute for Health and Clinical Excellence guidance it is now first-line adjuvant treatment for metastatic colorectal cancer in the UK. Although cardiac chest pain and myocardial ischaemia are well recognised side effects of 5-fluorouracil, their association with capecitabine is not widely appreciated. Two cases are described of coronary spasm secondary to capecitabine in patients referred for emergency invasive treatment of presumed ST elevation myocardial infarction (STEMI). The contemporary treatment of acute coronary syndromes involves aggressive antiplatelet therapy, anticoagulation and cardiac catheterisation. This treatment, although beneficial in most patients, is associated with a small but significant risk of bleeding complications. A wider appreciation of the potential for capecitabine to induce spasm mimicking STEMI is important in order to reduce the risk of the administration of thrombolytics and other potentially dangerous drugs and have a higher threshold for referral for emergency angiography.

Herbal ecstasy: cardiovascular complications of khat chewing in pregnancy.

Chewing fresh leaves of the Khat plant (Catha edulis Celestrasae) is a widespread habit (also practiced by women, even during pregnancy) with a deep-rooted tradition in East Africa and the Arabian Peninsula. With the influx of immigrants from East Africa and the Arabian Peninsula khat chewing has been imported into other countries including Europe the United States. The major pharmacologically active constituent of the fresh khat leaves is cathinone. Khat (also known as herbal ecstasy) is chewed for its central nervous system stimulant properties, which resemble amphetamine. Cardiovascular complications from cathinone use may therefore be similar to those of amphetamine. I herein present the first reported case of a pregnant patient who developed chest pain, tachycardia, and hypertension following khat-chewing session.

Cardiovascular adverse effects of herbal medicines: a systematic review of the recent literature.

Herbal medicines are popular but health care professionals often feel uncertain about their risks. This article summarizes recent evidence regarding the serious or potentially serious cardiovascular adverse effects of herbal medicines. Five electronic literature databases were searched. The evidence found was mostly anecdotal. Case reports and case series indicate that life-threatening adverse effects of herbal medicines occur. Potentially serious adverse effects are arrhythmias, arteritis, cardiac glycosides overdose, chest pain, congestive heart failure, hypertension, hypotension, myocardial infarction, over-anticoagulation, pericarditis and death. The problems relate to toxic herbal ingredients, adulteration and contamination of herbal medicinal products, and herb-drug interactions. Herbal medicines that have been implicated repeatedly include aconite, ephedra and licorice. Because of the anecdotal nature of the evidence, it is impossible to estimate the incidence of adverse effects. In conclusion, herbal medicinal products are regularly associated with serious cardiovascular adverse events but the size of this problem cannot be estimated at present. Vigilance and research seem to be the best way forward.

The safety of intravenous iron dextran (Dexferrum) during hemodialysis in patients with end stage renal disease.

The National Kidney Foundation recently published guidelines stating that regular use of intravenous iron therapy will prevent iron deficiency and promote better erythropoiesis than oral iron therapy in patients with end stage renal disease (ESRD) who are undergoing hemodialysis. Although intravenous iron dextran has been shown to be clinically effective in maintaining iron stores in such patients, some clinicians are concerned about the incidence of adverse events associated with this mode of iron supplementation. We conducted a retrospective review of adverse events associated with the use of Dexferrum (American Regent Laboratories, Inc., Shirley, NY) in ESRD patients at an outpatient dialysis clinic. During the 6-month study period, only 1 patient out of 62 (1.6%) experienced adverse events (hypotension, chest pain) related to treatment with Dexferrum. No patients developed anaphylactoid reactions.

The significance of excursions above the ADI. Case study: monosodium glutamate.

Monosodium glutamate (MSG) has been allocated an "ADI not specified" by the JECFA, which indicates that no toxicological concerns arise associated with its use as a food additive in accordance with good manufacturing practice (GMP) and for that reason it is not necessary to allocate a numerical ADI. The question in this case, then, is not whether excursions above a numerical ADI might occur but whether high peak intakes might arise which could invalidate the assumption of absence of hazard. Two major issues have arisen in relation to high intakes of MSG: (1) What is the significance of neural damage (focal necrosis in the hypothalamus) seen following high parenteral or intragastric doses of MSG to neonatal animals and is this a particular risk for children? (2) What is the role of MSG in "Chinese Restaurant Syndrome" (flushing, tightness of the chest, difficulty in breathing, etc.) following consumption of Chinese foods? In relation to the first issue, human studies have been crucial in resolving the question. The threshold blood levels associated with neuronal damage in the mouse (most sensitive species) are 100-130 mumol/dl in neonates rising to > 630 mumol/dl in adult animals. In humans, plasma levels of this magnitude have not been recorded even after bolus doses of 150 mg/kg body wt (ca. 10 g for an adult). Additionally, studies in infants have confirmed that the human baby can metabolize glutamate as effectively as adults. It is concluded that blood levels of glutamate + aspartate do not rise significantly even after abuse doses and babies are no more at risk than adults. Intake levels associated with the use of MSG as a food additive and natural levels of glutamic acid in foods therefore do not raise toxicological concerns even at high peak levels of intake. It is not envisaged that use of MSG according to GMP requires the allocation of a numerical ADI. With regard to the second issue, controlled double-blind crossover studies have failed to establish a relationship between Chinese Restaurant Syndrome and ingestion of MSG, even in individuals reportedly sensitive to Chinese meals, and MSG did not provoke bronchoconstriction in asthmatics. Thus, high usage of MSG in ethnic cuisines does not represent a situation in which intakes might achieve unsafe levels, even among individuals claiming idiosyncratic intolerance of such foods. In the light of the toxicological studies, the human metabolic studies in neonates and adults, and the physiological and nutritional role of glutamic acid and the fact that food additive use does not markedly increase the total dietary burden, no foreseeable circumstances arise in which intakes would be such as to invalidate the appropriateness of allocating an ADI not specified to MSG.

[Risk of lung damage found in fire-eaters. Twelve Swedish hospital cases reported]. / Risk för lungskador vid eldslukning. Tolv svenska sjukhusfall rapporterade.

Twelve hospital cases and 69 telephone enquiries relating to fire-eating have been registered at the Swedish Poison Information Centre. Chemical pneumonitis with symptoms such as coughing, fever, dyspnoea and hypoxia is common after petroleum distillate ingestion with concomitant aspiration. Pleuritic chest pain is an additional characteristic symptom among fire-eaters. Pulmonary infiltrates and pleural effusions are also frequent findings.

[Clinical analysis of 6 cases of gestational trophoblastic neoplasms complicated by cardiotoxicity after chemotherapies].

Gestational trophoblastic neoplasm treated by large dosage of 5-fluorouracil and actinomycin could cause cardiotoxicity. In 6 cases of gestational trophoblastic neoplasms admitted to our hospital from March to December 1993, cardiotoxicity was found to have occurred after chemotherapies in 10/21 courses. There were 2 cases with heart failures, 4 cases with palpitation and 4 cases with feelings of oppression and (or) chest pains. In 7 cases the electrocardiogram (EKG) findings were abnormal (70.0%) and in 5 cases there were increased sera glutamic oxalacetic transaminase enzyme (AST). 90.0% of these complications were brought under control after decreasing the dosages and changing the methods of administration. If the proper managements were not given on time, patient may even expire. So attention should be paid to this complication. It is suggested that attention should be paid to patients' subjective symptoms, and proper surveillance by EKG and serum AST determinations should be conducted to minimize deaths due to chemotherapeutic complications.