Chest pain during use of bupropion as an aid in smoking cessation

Bupropion-disguised chest pain presenting in a middle-aged male: a case report and review of literature

Introduction and importance

Chest pain is one of the most prevalent complaints amongst individuals presenting in healthcare settings, encompassing a broad spectrum of etiologies. Work-up for chest pain often focuses on excluding life-threatening conditions before the consideration of atypical causes.

Case presentation

A 47-year-old male with a past medical history of tobacco use and depression presented with persistent left-sided chest pain. Vitals on arrival were notable for mild hypertension. Two consecutive high-sensitivity troponins were unremarkable. The electrocardiogram showed sinus rhythm with no ischemic changes. Due to the atypical presentation of chest pain, the patient's home medications were reviewed, and his bupropion was discontinued due to concern for medication-induced chest pain. The patient was discharged and presented 2 days for follow-up endorsing complete resolution of his chest pain.

Clinical discussion

Prior investigations have shown bupropion to be associated with chest pain, with resolution noted after discontinuation. The etiology of chest pain is likely sympathomimetic, as bupropion has been shown to exhibit positive inotropic effects on myocardial tissue, propagated by catecholamine release.

Conclusion

Patients taking bupropion may present with atypical chest pain. Medication discontinuation may be beneficial in alleviating symptoms.

Exploring association between statin use and breast cancer risk: an updated meta-analysis

PURPOSE

The benefits of statin treatment for preventing cardiac disease are well established. However, preclinical studies suggested that statins may influence mammary cancer growth, but the clinical evidence is still inconsistent. We, therefore, performed an updated meta-analysis to provide a precise estimate of the risk of breast cancer in individuals undergoing statin therapy.

METHODS

For this meta-analysis, we searched PubMed, the Cochrane Library, Web of Science, Embase, and CINAHL for published studies up to January 31, 2017. Articles were included if they (1) were published in English; (2) had an observational study design with individual-level exposure and outcome data, examined the effect of statin therapy, and reported the incidence of breast cancer; and (3) reported estimates of either the relative risk, odds ratios, or hazard ratios with 95% confidence intervals (CIs). We used random-effect models to pool the estimates.

RESULTS

Of 2754 unique abstracts, 39 were selected for full-text review, and 36 studies reporting on 121,399 patients met all inclusion criteria. The overall pooled risks of breast cancer in patients using statins were 0.94 (95% CI 0.86-1.03) in random-effect models with significant heterogeneity between estimates (I ² = 83.79%, p = 0.0001). However, we also stratified by region, the duration of statin therapy, methodological design, statin properties, and individual stain use.

CONCLUSIONS

Our results suggest that there is no association between statin use and breast cancer risk. However, observational studies cannot clarify whether the observed epidemiologic association is a causal effect or the result of some unmeasured confounding variable. Therefore, more research is needed.

Depression with panic episodes and coronary vasospasm

Variant (Prinzmetal's) angina is an uncommon cause of precordial pain caused by coronary vasospasm and characterized by transient ST elevation and negative markers of myocardial necrosis. This is the case of a female patient with a prior history of depression and panic attacks who presented with recurrent symptoms including chest pain. A cardiac event monitor positively documented coronary vasospasm associated with anxiety-provoking chest pain, whereas the coronary arteries were angiographically normal. We noted that the frequency of angina attacks apparently increased during the period that coincided with the introduction of Bupropion SR for treatment of the patient's depression. Considering the possibility of bupropion-associated negative impact on coronary vasospasm, the antidepressant therapy was adjusted to exclude this drug. Although Prinzmetal's angina is relatively uncommon, we suspect that a routine use of cardiac event monitors in subjects with panic disorder might reveal a greater incidence of coronary vasospasm in this patient population.

The association among depressive symptoms, smoking status and antidepressant use in cardiac outpatients

Both depression and smoking are highly prevalent and related to poorer outcomes in cardiac patients. In this study, the authors examined the association between depressive symptoms and smoking status, described the frequency and type of antidepressant use, and prospectively tested the effects of antidepressant use in smokers on smoking status and psychosocial outcomes. Participants comprised 1,498 coronary artery disease (CAD) outpatients who completed a baseline survey which assessed depressive symptoms, current medications, and smoking status. A second survey was mailed 9 months later that assessed depressive symptoms, anxiety, insomnia and smoking status. Results showed that current and former-smokers had significantly greater depressive symptoms than non-smokers. Ten percent of patients were taking antidepressants, most frequently SSRIs, with significantly more smokers on antidepressants than former and non-smokers. At follow-up, smokers on antidepressants were less likely to have quit, had greater anxiety, depressive symptoms and insomnia than smokers not using antidepressants. This study demonstrated that smokers and quitters with CAD had greater depressive symptoms and use of antidepressants than non-smokers, but that the antidepressants utilized may not be optimizing outcomes.

Hemodynamic effects of bupropion in anesthetized dogs

Bupropion is a non-nicotinic drug used in smoking cessation therapy. However, its acute effects remain unclear. In this study, we investigated the effects of bupropion on hemodynamic parameters in pentobarbital-anesthetized mongrel dogs. Bupropion administered either in bolus injections (3 or 6 mg/kg, i.v.) or in cumulative doses of 0.01, 0.1, 1, 3 and 10 mg/kg showed, in both studies, a significant increase of mean pulmonary arterial pressure and pulmonary vascular resistance index. These results show that bupropion can elevate the pulmonary pressure. Further investigations should be done to test this effect in smokers with chronic obstructive pulmonary disease.