515765 research-article2014
TAK0010.1177/1753944713515765Therapeutic Advances in Cardiovascular DiseaseT Kivrak, M Sunbul
Therapeutic Advances in Cardiovascular Disease
Acute myocardial infarction due to liquid nicotine in a young man Tarik Kivrak, Murat Sunbul, Erdal Durmus, Ramile Dervisova, Ibrahim Sari and Osman Yesildag
Letter to the Editor
Ther Adv Cardiovasc Dis 2014, Vol. 8(1) 32–34 DOI: 10.1177/ 1753944713515765 © The Author(s), 2014. Reprints and permissions: http://www.sagepub.co.uk/ journalsPermissions.nav
Keywords: liquid nicotine, myocardial infarction, smoking Introduction Myocardial infarction is rare in people under the age of 30. The pathogenesis of coronary artery disease (CAD) is known to be different in this age group than their older counterparts. Atherosclerotic burden is less and thrombotic burden is more prominent in younger patients. Nicotine has toxic effects on the endothelium, might alter vascular reactivity, cause vasospasm and activate platelets. We present here a rare case of acute myocardial infarction in a 24-year-old man due to liquid nicotine which has not been reported previously. Case report A previously healthy 24-year-old man presented to the emergency department with typical chest pain that began 4 hours ago while he was using liquid nicotine. Immediate electrocardiogram revealed sinus rhythm with a heart rate of 72 beats per minute and normal axis, however there were ST segment elevation on leads DI, aVL and V1-6 with reciprocal ST segment depression and T wave inversion on leads aVF, DII and DIII (Figure 1A). His physical examination was normal. Transthoracic echocardiography displayed anterior wall hypokinesis (ejection fraction: 50%). Highly sensitive troponin-T level was 223 pg/ml (normal range: 0–14 pg/ml). He was transferred to cardiac catheterization laboratory, which revealed thrombus in the proximal left anterior descending artery (Figure 2A). There was no other coronary lesion. Because the patient was young and had no other known risk factors for CAD, we decided to administer tissue plasminogen activator (Alteplase, 100 mg IV), after which the chest pain disappeared and the electrocardiogram showed more than 70% of resolution of ST elevation (Figure 1B). Predischarge control
angiography displayed complete resolution of the thrombus (Figure 2B). He had been smoking one packet of cigarettes daily for 4 years but had given up smoking 1 month prior to admission. After that time he has been using liquid tobacco containing 16 mg nicotine daily. The amount of nicotine in the liquid nicotine approximately corresponds to the level in one packet of cigarettes. There was no family history of cardiovascular disease or any other risk factor. Drug-induced coronary spasm was less likely because urine toxicology screen was negative. Tendency to thromboembolism including antiphospholipid syndrome, factor V Leiden mutation, proteins C and S deficiencies and connective tissue diseases were screened and excluded. The patient was discharged with acetylsalicylic acid 100 mg, clopidogrel 75 mg, atorvastatin 10 mg and diltiazem 120 mg. He was evaluated a month later and was found to be free of any symptoms.
Correspondence to: Murat Sunbul, MD Marmara University Faculty of Medicine, Department of Cardiology, Fevzi Cakmak Mahallesi, Mimar Sinan Caddesi, No. 41, Ustkaynarca, Pendik, Istanbul, Turkey [email protected] Tarik Kivrak, MD Erdal Durmus, MD Ramile Dervisova, MD Ibrahim Sari, MD Osman Yesildag, MD Marmara University Faculty of Medicine, Department of Cardiology, Istanbul, Turkey
Discussion Myocardial infarction is rarely seen in young patients and only 2–6% of all myocardial infarctions occur in people under the age of 45 years [Jalowiec and Hill, 1989]. The prevalence of CAD is reported to be 0.5% in men between 35 and 44 years and 20.5% in men over the age of 60 years [Office of National Statistics, 2000; Choudhury and Marsh, 1999]. Coronary anomaly may also cause acute coronary syndrome (ACS) in young patients [Sunbul et al. 2013; Shah and Redmond, 2010]. Diagnostic differentiation is important for ACS in young patients because treatment choices may range from surgery to percutaneous coronary intervention according to diagnosis. The pathogenesis has been explained by different mechanisms
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T Kivrak, M Sunbul et al.
Figure 1. (A) Surface ECG showing ST segment elevation on leads DI, aVL and V1-6 with reciprocal ST segment depression and T wave inversion on leads aVF, DII and DIII. (B) Surface ECG showing more than 70% of resolution of ST segment elevation after thrombolytic therapy.
Figure 2. (A) Coronary angiography showing thrombus in the proximal left anterior descending artery. (B) Control coronary angiography showing complete resolution of the thrombus in the proximal left anterior descending artery. http://tac.sagepub.com 33
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Therapeutic Advances in Cardiovascular Disease 8(1)
Visit SAGE journals online http://tac.sagepub.com
SAGE journals
for the presence of CAD in young patients. Smoking, familial hypercholesterolemia and obesity are the most significant risk factors associated with CAD in young adults. Our patient had no risk factors other than smoking. He had 4 pack-years history of smoking. He had a heart attack while he was using liquid nicotine. Nicotine has toxic effects on endothelium and thus may play a key role in impaired nitric oxide synthase (NOS)-dependent vasodilatation. Nicotine produces morphologic abnormalities on the endothelium causing direct alteration of the vascular reactivity. It effects α-2 receptors by the release of catecholamine and leads to severe vasoconstriction and might cause a myocardial infarction. Nicotine, directly or indirectly through the release of endogenous epinephrine, has been shown to increase platelet aggregation [Renaud et al. 1984]. We thought that myocardial infarction was associated with the use of nicotine by way of the above-mentioned mechanisms. Our case report has important clinical implications. Although smoking is an important risk factor for CAD, high-dose nicotine may be fatal for young subjects. Therefore, a detailed history of the patient is essential to initiate the appropriate therapy. On the other hand, coronary anomaly should also be ruled out in young patients presenting with ACS. Finally, thrombolytic therapy may be the better treatment choice in young patients who present with ACS, because the atherosclerotic burden is less and thrombotic burden is more prominent in younger patients.
Funding This research received no specific grant from any funding agency in the public, commercial, or notfor-profit sectors. Conflict of interest statement The authors declare no conflicts of interest in preparing this article.
References Choudhury, L. and Marsh, J. (1999) Myocardial infarction in young patients. Am J Med 107: 254–261. Jalowiec, D. and Hill, J. (1989) Myocardial infarction in the young and in women. Cardiovasc Clin 20: 197–206. Office of National Statistics (2000) Key health statistics from General Office, 2000. http://www. statistics.gov.uk/health and care. Renaud, S., Blache, D., Dumont, E., Thevenon, C. and Wissendanger, T. (1984) Platelet function after cigarette smoking in relation to nicotine and carbon monoxide. Clin Pharmacol Ther 36: 389–395. Shah, A. and Redmond, M. (2010) Single coronary artery; extremely rare coronary anomaly successfully treated surgically in young adult male. Ir Med J 103: 150–151. Sunbul, M., Samedov, F., Sari, I. and Ozben, B. (2013) A serious cause of syncope in a young patient. Herz. DOI: 10.1007/s00059-013-3771-9.
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TAK0010.1177/1753944713515765Therapeutic Advances in Cardiovascular DiseaseT Kivrak, M Sunbul
Therapeutic Advances in Cardiovascular Disease
Acute myocardial infarction due to liquid nicotine in a young man Tarik Kivrak, Murat Sunbul, Erdal Durmus, Ramile Dervisova, Ibrahim Sari and Osman Yesildag
Letter to the Editor
Ther Adv Cardiovasc Dis 2014, Vol. 8(1) 32–34 DOI: 10.1177/ 1753944713515765 © The Author(s), 2014. Reprints and permissions: http://www.sagepub.co.uk/ journalsPermissions.nav
Keywords: liquid nicotine, myocardial infarction, smoking Introduction Myocardial infarction is rare in people under the age of 30. The pathogenesis of coronary artery disease (CAD) is known to be different in this age group than their older counterparts. Atherosclerotic burden is less and thrombotic burden is more prominent in younger patients. Nicotine has toxic effects on the endothelium, might alter vascular reactivity, cause vasospasm and activate platelets. We present here a rare case of acute myocardial infarction in a 24-year-old man due to liquid nicotine which has not been reported previously. Case report A previously healthy 24-year-old man presented to the emergency department with typical chest pain that began 4 hours ago while he was using liquid nicotine. Immediate electrocardiogram revealed sinus rhythm with a heart rate of 72 beats per minute and normal axis, however there were ST segment elevation on leads DI, aVL and V1-6 with reciprocal ST segment depression and T wave inversion on leads aVF, DII and DIII (Figure 1A). His physical examination was normal. Transthoracic echocardiography displayed anterior wall hypokinesis (ejection fraction: 50%). Highly sensitive troponin-T level was 223 pg/ml (normal range: 0–14 pg/ml). He was transferred to cardiac catheterization laboratory, which revealed thrombus in the proximal left anterior descending artery (Figure 2A). There was no other coronary lesion. Because the patient was young and had no other known risk factors for CAD, we decided to administer tissue plasminogen activator (Alteplase, 100 mg IV), after which the chest pain disappeared and the electrocardiogram showed more than 70% of resolution of ST elevation (Figure 1B). Predischarge control
angiography displayed complete resolution of the thrombus (Figure 2B). He had been smoking one packet of cigarettes daily for 4 years but had given up smoking 1 month prior to admission. After that time he has been using liquid tobacco containing 16 mg nicotine daily. The amount of nicotine in the liquid nicotine approximately corresponds to the level in one packet of cigarettes. There was no family history of cardiovascular disease or any other risk factor. Drug-induced coronary spasm was less likely because urine toxicology screen was negative. Tendency to thromboembolism including antiphospholipid syndrome, factor V Leiden mutation, proteins C and S deficiencies and connective tissue diseases were screened and excluded. The patient was discharged with acetylsalicylic acid 100 mg, clopidogrel 75 mg, atorvastatin 10 mg and diltiazem 120 mg. He was evaluated a month later and was found to be free of any symptoms.
Correspondence to: Murat Sunbul, MD Marmara University Faculty of Medicine, Department of Cardiology, Fevzi Cakmak Mahallesi, Mimar Sinan Caddesi, No. 41, Ustkaynarca, Pendik, Istanbul, Turkey [email protected] Tarik Kivrak, MD Erdal Durmus, MD Ramile Dervisova, MD Ibrahim Sari, MD Osman Yesildag, MD Marmara University Faculty of Medicine, Department of Cardiology, Istanbul, Turkey
Discussion Myocardial infarction is rarely seen in young patients and only 2–6% of all myocardial infarctions occur in people under the age of 45 years [Jalowiec and Hill, 1989]. The prevalence of CAD is reported to be 0.5% in men between 35 and 44 years and 20.5% in men over the age of 60 years [Office of National Statistics, 2000; Choudhury and Marsh, 1999]. Coronary anomaly may also cause acute coronary syndrome (ACS) in young patients [Sunbul et al. 2013; Shah and Redmond, 2010]. Diagnostic differentiation is important for ACS in young patients because treatment choices may range from surgery to percutaneous coronary intervention according to diagnosis. The pathogenesis has been explained by different mechanisms
32 http://tac.sagepub.com
Downloaded from tak.sagepub.com by guest on November 14, 2015
T Kivrak, M Sunbul et al.
Figure 1. (A) Surface ECG showing ST segment elevation on leads DI, aVL and V1-6 with reciprocal ST segment depression and T wave inversion on leads aVF, DII and DIII. (B) Surface ECG showing more than 70% of resolution of ST segment elevation after thrombolytic therapy.
Figure 2. (A) Coronary angiography showing thrombus in the proximal left anterior descending artery. (B) Control coronary angiography showing complete resolution of the thrombus in the proximal left anterior descending artery. http://tac.sagepub.com 33
Downloaded from tak.sagepub.com by guest on November 14, 2015
Therapeutic Advances in Cardiovascular Disease 8(1)
Visit SAGE journals online http://tac.sagepub.com
SAGE journals
for the presence of CAD in young patients. Smoking, familial hypercholesterolemia and obesity are the most significant risk factors associated with CAD in young adults. Our patient had no risk factors other than smoking. He had 4 pack-years history of smoking. He had a heart attack while he was using liquid nicotine. Nicotine has toxic effects on endothelium and thus may play a key role in impaired nitric oxide synthase (NOS)-dependent vasodilatation. Nicotine produces morphologic abnormalities on the endothelium causing direct alteration of the vascular reactivity. It effects α-2 receptors by the release of catecholamine and leads to severe vasoconstriction and might cause a myocardial infarction. Nicotine, directly or indirectly through the release of endogenous epinephrine, has been shown to increase platelet aggregation [Renaud et al. 1984]. We thought that myocardial infarction was associated with the use of nicotine by way of the above-mentioned mechanisms. Our case report has important clinical implications. Although smoking is an important risk factor for CAD, high-dose nicotine may be fatal for young subjects. Therefore, a detailed history of the patient is essential to initiate the appropriate therapy. On the other hand, coronary anomaly should also be ruled out in young patients presenting with ACS. Finally, thrombolytic therapy may be the better treatment choice in young patients who present with ACS, because the atherosclerotic burden is less and thrombotic burden is more prominent in younger patients.
Funding This research received no specific grant from any funding agency in the public, commercial, or notfor-profit sectors. Conflict of interest statement The authors declare no conflicts of interest in preparing this article.
References Choudhury, L. and Marsh, J. (1999) Myocardial infarction in young patients. Am J Med 107: 254–261. Jalowiec, D. and Hill, J. (1989) Myocardial infarction in the young and in women. Cardiovasc Clin 20: 197–206. Office of National Statistics (2000) Key health statistics from General Office, 2000. http://www. statistics.gov.uk/health and care. Renaud, S., Blache, D., Dumont, E., Thevenon, C. and Wissendanger, T. (1984) Platelet function after cigarette smoking in relation to nicotine and carbon monoxide. Clin Pharmacol Ther 36: 389–395. Shah, A. and Redmond, M. (2010) Single coronary artery; extremely rare coronary anomaly successfully treated surgically in young adult male. Ir Med J 103: 150–151. Sunbul, M., Samedov, F., Sari, I. and Ozben, B. (2013) A serious cause of syncope in a young patient. Herz. DOI: 10.1007/s00059-013-3771-9.
34 http://tac.sagepub.com
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