Profound Coronary Vasospasm Associated with Intraoperative Ketamine Administration: A Case Report

We report a case of a 62-year-old woman with a decade-long history of atypical chest pain resulting in a largely negative cardiac workup, who developed significant angiographically demonstrated coronary vasospasm thought to be due to a small dose of intravenous ketamine. In patients with a history of atypical chest pain despite a reassuring cardiac evaluation, providers should carefully consider medications that may precipitate coronary vasospasm and be prepared to treat it accordingly.

Atherosclerosis Vindicated: A Case of Chest Pain Due to Capecitabine-Induced Coronary Artery Spasm

BACKGROUND Capecitabine and other 5-fluorouracil prodrugs are medications widely employed in treating solid tumors, including breast and colorectal cancer. However, they carry a notable risk for cardiotoxicity, including coronary vasospasm, possibly related to their impact on vascular endothelium and smooth muscle. CASE REPORT We present a case of a 45-year-old male with a pancreatic neuroendocrine tumor who developed exertional chest pain after starting capecitabine. Initial evaluations in the emergency department, including a 12-lead electrocardiogram and cardiac enzymes, were normal, but suspicion for coronary vasospasm persisted due to the temporal relationship with drug initiation and symptom characteristics. A graded exercise test reproduced his symptoms, accompanied by hyperacute peaked T waves and subsequent ST segment elevations in the inferior leads. Coronary angiography revealed patent coronary arteries, rendering provocative testing unnecessary due to a high clinical suspicion of capecitabine-induced vasospasm. Discontinuing the patient's medication was a more efficient approach than continuing additional cardiac workup while the drug was still administered. After multidisciplinary discussion, capecitabine was discontinued, leading to symptom resolution and a negative repeat graded exercise test. CONCLUSIONS This case underscores the potential for capecitabine to induce coronary artery vasospasm, emphasizing the importance of prompt medication cessation. Patients receiving capecitabine therapy and experiencing chest pain should undergo an evaluation with consideration of capecitabine-induced vasospasm in the differential diagnosis. Prompt recognition and medication cessation are critical to prevent serious cardiovascular complications including death. In our patient, discontinuing capecitabine resolved his symptoms, emphasizing the significance of discontinuing the causative drug and seeking alternative chemotherapy regimens.

Methylphenidate-associated chest pain in a child

A young child was diagnosed with autism spectrum disorder with comorbid attention-deficit/hyperactivity disorder. His hyperactivity, impulsivity and absence of awareness towards danger increased his risk of harm and hence methylphenidate was indicated. Unfortunately, he developed chest pain eight months after the treatment initiation. We then stopped the stimulant and changed his treatment to atomoxetine, after which he no longer had chest pain. In the following illustrated case, we will discuss the cardiac side effect of methylphenidate.

Wellens syndrome during chemotherapy for cholangiocarcinoma: A case report of cardiovascular toxicity associated with gemcitabine-containing regimen

RATIONALE

Wellens syndrome is a comprehensive electrocardiographic (ECG) diagnosis that combines medical history with characteristic ECG changes. These changes, characterized by biphasic T-wave inversions or symmetric and deep T-wave inversions in the anterior precordial leads, often indicate that the left anterior descending coronary artery is at a high risk of severe stenosis. Chemotherapy-related cardiovascular toxicity refers to damage to the cardiovascular system caused by chemotherapeutic drugs, which is unpredictable and may occur during or after chemotherapy.

PATIENT CONCERNS

In this case report, a 41-year-old male patient with cholangiocarcinoma received sequential adjuvant chemotherapy with gemcitabine/nanoparticle albumin-bound paclitaxel and gemcitabine/cisplatin. This patient presented with recurrent brief chest pain episodes after the third dose of gemcitabine/cisplatin, and the characteristic T-wave morphological changes were captured in routine ECG monitoring prior to the 6th dose.

DIAGNOSES

Acute coronary syndrome due to chemotherapy-related cardiovascular toxicity was diagnosed on the basis of characteristic ECG changes.

INTERVENTIONS

The patient underwent coronary angiography, which revealed diffuse stenosis of up to 95% in the middle segment of the left anterior descending coronary artery. Stents were implanted in the stenotic segment for vascular reconstruction.

OUTCOMES

The patient's chest pain was completely resolved, and electrocardiography returned to normal.

LESSONS

Cardiovascular toxicity during chemotherapy in patients with cancer may be life threatening. This rare case highlights the importance of identifying the characteristic ECG pattern of the Wellens syndrome by monitoring electrocardiography during chemotherapy. Immediate and accurate identification of the morphological ECG features of Wellens syndrome with a slight elevation of the ST-segment is related to patient prognosis.

Prevalence of myocardial infarction among patients with chest pain and cocaine use: A systematic review and meta-analysis

BACKGROUND

Cocaine abuse is a public health burden. Cocaine is known to cause vasospasm and acute myocardial infarction (AMI). The prevalence of AMI in patients presenting with chest pain and concurrent cocaine use (CPCC) varies among studies. We performed a systemic review and meta-analysis to assess the current literature for the prevalence of AMI in patients with CPCC.

METHODS

We performed a literature search of PubMed, EMBASE, and Scopus from its beginning to May 18, 2020 and updated this search on February 18, 2021. Full-text studies that assessed the primary outcome (AMI) specifically among patients with CPCC who presented to the emergency department (ED) were included. We excluded studies that were not in English, did not take place in the ED, and case reports, which only reported positive cases and not incidence of AMI. Random effect meta-analysis was performed to assess the prevalence of primary outcome and to examine correlations between risk factors and AMI. Heterogeneity was assessed by I-square value. We also performed subgroup analysis to identify potential sources of heterogeneity.

RESULTS

We identified 2178 studies and screened 102 full-text studies to include 16 studies (3269 patients) in our final analysis. The pooled prevalence of AMI was 4.7% (95% CI 0.8-23), I-square of 84%. However, rates among studies of low risk patients were lower (1.1% 95% CI 0.2-5) compared to studies of mixed risk patients (7.7%, 95% 5-11). A meta-regression was used to look at correlation between risk factors and AMI and found that AMI was positively correlated in patients with a history of CAD (correlation coefficient [Corr. Coeff.] 5.6, 96% CI 2.3-8.7), HTN (Corr. Coeff. 2.9, 95% CI 0.9-4.9), DM (Corr. Coeff. 8.0, 95% CI 2.4-14), HLD (Corr. Coeff. 5.9, 95% CI 2.4, 9). Sources of potential heterogeneity included patients' risk as defined by the authors, study designs, publication year, and study sample size.

CONCLUSION

The overall prevalence of AMI and death among patients with cocaine-associated chest pain was relatively low, although high risk patients were still associated with high prevalence of AMI. Clinicians should consider risk-stratify these patients and treat them accordingly.

Marijuana-associated ST-elevation myocardial infarction: is this a benign drug

Marijuana is the most commonly used psychoactive drug in the USA. A 35-year-old man with a medical history of marijuana abuse is admitted to the hospital due to crushing substernal chest pain. ECG shows evolving ST-segment elevation with a rise in cardiac enzymes, consistent with ST-elevation myocardial infarction. A urine toxicology screen is positive for cannabis and negative for cocaine and other stimulant drugs. An emergent cardiac catheterisation reveals no evidence of coronary artery disease or thrombosis. A diagnosis of coronary vasospasm is strongly considered, and the patient is started on calcium channel blocker, with a resolution of symptoms and ECG changes. Marijuana-induced coronary spasm causing myocardial infarction has rarely been reported. Marijuana is becoming a social norm in adolescents and there remains a misconception that it is harmless and even beneficial. Increasing drug abuse remains a public health concern, necessitating population education by physicians for safer healthcare practices.

Association between fine particulate air pollution and hospital admissions for chest pain in a subtropical city: Taipei, Taiwan

This study determined the association between fine particles (PM_2.5) levels and hospital admissions for chest pain (CP) in Taipei, Taiwan. Hospital admissions for CP and ambient air pollution data for Taipei were obtained for the period 2009-2013. The relative risk of hospital admissions was estimated using a case-crossover approach, after controlling for weather variables, day of the week, seasonality, and long-term time trends. For single-pollutant models (without adjustment for other pollutants), increased frequency of CP admissions was significantly associated with PM_2.5 levels on warm days (>23°C), with an interquartile range rise correlated with a 15% (95% confidence interval = 11-31%) elevation in number of CP admissions. In two-pollutant models, PM_2.5 remained significant after inclusion of each of the other four pollutants: sulfur dioxide (SO₂), nitrogen dioxide (NO₂), carbon monoxide (CO), and ozone (O₃) on warm days. Generally, no marked associations were observed between PM_2.5 levels and risk of CP admissions on cool days in both single- and two-pollutant models. This study provides evidence that higher PM_2.5 concentrations enhance the risk of hospital admissions for CP on warm days.

Incidence and risk factors for capecitabine-induced symptomatic cardiotoxicity: a retrospective study of 452 consecutive patients with metastatic breast cancer

OBJECTIVES

Case reports of capecitabine cardiotoxicity resemble those seen with intravenous 5-fluorouracil (5-FU) with chest pain as the predominant manifestation, but few studies of capecitabine cardiotoxicity are available. We aimed to determine the incidence of symptomatic cardiotoxicity from capecitabine in patients with breast cancer and to identify risk factors.

METHODS

We reviewed medical records of consecutive women with breast cancer treated with capecitabine (1000 mg/m² two times per day) from 2002 to 2012 at one institution.

RESULTS

22 of 452 patients (4.9%) (95% CI 2.9% to 6.9%) had symptoms of cardiotoxicity (chest pain: n=13, dyspnoea: n=9, palpitations: n=2). 11 patients had changes on ECG (atrial fibrillation: n=5, ST deviations: n=3, T-wave abnormalities: n=2 and QTc prolongation: n=1). 2 patients (0.4%) sustained acute myocardial infarction. 1 patient (0.2%) developed cardiac arrest with lethal outcome. 4 of 6 patients (66%) retreated with capecitabine had recurrent symptoms at retreatment. Cardiac comorbidity (p=0.001), hypercholesterolaemia (p=0.005) and current smoking (p=0.023) were risk factors for cardiotoxicity in univariate analyses and remained significant when adjusted for age. Patients with cardiac comorbidity were 5.5 times (95% CI 2.0 to 14.8) more likely to develop cardiotoxicity. In the subgroup of patients with apparently no cardiac comorbidity, the incidence of cardiotoxicity was lower (3.7%) and hypercholesterolaemia (p=0.035) and current smoking (p=0.020) were risk factors of cardiotoxicity.

CONCLUSIONS

The incidence of cardiotoxicity from capecitabine resembles that of intravenous 5-FU (≈5%). Cardiac comorbidity, hypercholesterolaemia and current smoking were associated with development of cardiotoxicity.

Case of low dose clenbuterol toxicity

We present a case of acute clenbuterol toxicity following ingestion of 20 μg of clenbuterol, resulting in symptoms of sympathetic activation, sinus tachycardia and electrolyte derangement. The patient was managed conservatively with fluid resuscitation, electrolyte replacement and monitoring, and discharged following a 5-day stay in hospital.

Quetiapine-induced myocarditis presenting as acute STEMI

An 18-year-old man diagnosed with attention-deficit hyperactivity disorder was recently started on quetiapine in addition to regular methylphenidate, which he had been taking for a number of years. He presented with chest pain and inferolateral ST elevation, and underwent urgent coronary angiography, which showed normal coronary arteries. The initial troponin level was raised and an inpatient echocardiogram showed mild left ventricular systolic dysfunction with no evidence of regional wall motion abnormality. Cardiac MRI showed subepicardial late gadolinium enhancement, which was suggestive of myocarditis. Quetiapine and methylphenidate were discontinued and the patient was discharged home after 1 week. He was followed up within 8 weeks with complete recovery and no symptoms.

Esophagitis due to dexketoprofen trometamol: a rare case report

Various drugs are known to cause pill esophagitis. Antimicrobial drugs and nonsteroidal anti-inflammatory drugs are the most common causes of pill-induced esophagitis. Most patients suffer only self-limiting pain, but serious complications can occur. A 21-year-old man was admitted to our outpatient clinic with retrosternal chest pain, dysphagia, and odynophagia complaints, which occurred within 2 weeks after starting dexketoprofen trometamol. An upper endoscopy system examination revealed three well-demarcated ulcers in the esophagus at 35 cm from the incisors. Dexketoprofen trometamol may cause esophageal lesions. This rare disorder should be considered in patients presenting with sudden-onset retrosternal pain in addition to dysphagia and odynophagia.

Incidence of reversible defect seen on myocardial perfusion scintigraphy using dipyridamole pharmacologic test early after primary percutaneous coronary intervention: how safe is it to perform this protocol?

INTRODUCTION

The purpose of this study was to investigate the safety of performing a dipyridamole stress test and to explore the incidence of reversible perfusion defects on myocardial perfusion imaging, five to six days after primary percutaneous coronary intervention (PCI).

METHODS

Forty-one patients underwent myocardial perfusion imaging using a dipyridamole stress test, five to six days after primary PCI.

RESULTS

Headache, chest pain, and dizziness were the most common side effects seen after dipyridamole administration. All occurrences were mild and short lasting. ST changes on the electrocardiogram were also seen in 12% of patients. Reversible perfusion defects occurred in 17%.

CONCLUSIONS

This is one of the few studies to investigate patients using a dipyridamole stress test early after primary PCI. We conclude that it is safe to perform myocardial perfusion imaging under dipyridamole administration, just a few days after primary PCI. Additionally, a high incidence (17%) of myocardial perfusion defects was seen in this group of patients. According to our investigational protocol, a second myocardial perfusion imaging examination is scheduled for six months later, in order to clarify how many of these patients suffer from restenosis, or whether the finding was merely due to early endothelial dysfunction.

[Efficacy and safety of medication use for the cessation of tobacco addiction: A review of Clinical Practice Guidelines]

OBJECTIVE

To review the efficacy and safety of pharmacotherapy for smoking cessation in the context of clinical practice guidelines (CPG).

METHODS

A systematic review of CPGs was conducted, aimed at adapting recommendations for Colombia following the ADAPTE methodology. Outcomes comprised 6-months or higher smoking cessation rates and intervention safety. CPGs were peer-assessed based on DELBI. Results from aggregative studies included in selected CPGs were obtained.

RESULTS

Pharmacotherapy doubles smoking cessation rates as compared with placebos (rates @25% and up to 27 % when combined with counseling). The highest efficacy was observed for ansyolitic and antidepressive drugs (8.7 % to 19.4 %), and the lowest for nicotine replacement therapy -NRT- (5.2 % to 12.9 %). Nortriptiline shows an efficacy similar to that of bupropion (@10%). With limited exceptions, combined pharmacotherapy for smoking cessation has shown no significant increase in cessation rates.

CONCLUSIONS

NRT, varenicline, bupropion and nortriptiline are effective treatments for smoking cessation. Combination of drugs deserves further clinical evidence and should be restricted to highly dependent smokers or initial therapeutic failure. Cost-effectiveness analyses might help to introduce smoking cessation programs in low and middle income countries.

Clinical and endoscopic characteristics of drug-induced esophagitis

AIM: To investigate clinical, endoscopic and pathological characteristics of drug-induced esophagitis.

METHODS: Data for patients diagnosed with drug-induced esophagitis from April 2002 to May 2013 was reviewed. Patients diagnosed with malignancy, viral or fungal esophagitis were excluded. Clinical, endoscopic and pathological characteristics of patients diagnosed with drug-induced esophagitis were analyzed.

RESULTS: Seventy-eight patients were diagnosed with drug-induced esophagitis. Their mean age was 43.9 ± 18.9 years and 35.9% were male. Common symptoms were chest pain (71.8%), odynophagia (38.5%) and dysphagia (29.5%). The endoscopic location was in the middle third of esophagus in 78.2%. Endoscopic findings were ulcer (82.1%), erosion (17.9%), ulcer with bleeding (24.4%), coating with drug material (5.1%), impacted pill fragments (3.8%) and stricture (2.6%). Kissing ulcers were observed in 43.6%. The main causative agents were antibiotics and non-steroidal anti-inflammatory drugs. All the patients were treated with proton pump inhibitors (PPIs) or sucralfate, and the causative drugs were discontinued. Nineteen patients with drug-induced esophagitis were followed up with endoscopy and revealed normal findings, scars or healing ulcers.

CONCLUSION: Drug-induced esophagitis mainly presents as chest pain, odynophagia and dysphagia, and may be successfully treated with PPIs and discontinuation of the causative drug. Kissing ulcers were observed in 43.6%.

Comparison of in-hospital outcomes for beta-blocker use versus non-beta blocker use in patients presenting with cocaine-associated chest pain

Beta blockers are indicated for management of acute coronary syndromes, but they generally are withheld in patients with cocaine-associated chest pain because of concerns for adverse outcomes related to the unique physiological effects of cocaine. Because few clinical studies have evaluated this interaction, we identified patients with toxicology screen results positive for cocaine treated for chest pain at 2 academic hospitals. Clinical characteristics and in-hospital outcomes were compared between patients with and without β-blocker therapy. We then constructed propensity scores to evaluate the independent relation between β-blocker use and the composite primary end point of myocardial infarction, stroke, ventricular arrhythmia, or all-cause mortality after adjusting for clinical characteristics. Of 376 consecutive patients with cocaine-related chest pain, β blockers were used in 164 (44%). Compared with no β blockers, patients treated with β blockers were more likely to describe anginal chest pain, to have known cardiovascular risk factors, and to receive other antiatherosclerotic therapies. Despite these higher risk clinical characteristics, patients treated with β blockers experienced similar peak troponin levels, individual adverse events, and rates of the composite primary end point (15.9% vs 12.3%, p = 0.32). The primary end point also was similar after propensity score analysis (odds ratio 1.37, 95% confidence interval 0.64 to 2.93, p = 0.42), including specific comparisons of beta-1 selective (odds ratio 1.83, 95% confidence interval 0.79 to 4.24) and nonselective (odds ratio 0.90, 95% confidence interval 0.33 to 2.42) β blockers, when compared with patients not receiving β blockers. In conclusion, no differences in outcomes were observed between patients treated versus not treated with β-blocker therapy in the setting of cocaine-related chest pain.

Acute adverse reactions to iopromide vs iomeprol: a retrospective analysis of spontaneous reporting from a radiology department

OBJECTIVE

To compare the safety of iopromide and iomeprol use in a hospital that switched from the former to the latter and found an apparent increase in the number (and a different profile) of adverse reactions reported for iomeprol, putting the safety of its use into question.

METHODS

This was a retrospective study of cases of acute reactions to iopromide and iomeprol reported in two successive time periods. Data from examinations using iopromide (62539 CT scans and 10348 urography scans) and iomeprol (34308 CT scans and 2846 urography scans) were obtained from the computer system of the hospital.

RESULTS

For each period, 154 cases of reactions were reported for iopromide and 86 for iomeprol, being severe in 10 (6.5%) patients for iopromide vs 17 (19.8%) patients for iomeprol; a statistically significant difference of p<0.003 was recorded. The most frequent adverse reactions (%/%) for iopromide/iomeprol were urticaria (29.1/17.2), pruritus (22.6/15.6), upper respiratory tract signs and symptoms (12.1/16.7), oedema (4.3/0), erythemas (3.4/5.0), nausea or vomiting (1.2/11.7) and chest pain (0/3.9) (p<0.0001 for the global comparison). The distribution of the reactions (%/%) by System Organ Class for iopromide/iomeprol was skin (56.7/41.1), respiratory (19.2/26.7), vascular (6.8/2.2), general (5.3/7.2), gastrointestinal (4.6/15.0) and others (7.4/7.9) (p<0.0002 for the global comparison).

CONCLUSION

Adverse reactions were more severe for iomeprol. Skin and vascular reactions with no chest pain were more frequent for iopromide, whereas gastrointestinal reactions were more frequent for iomeprol.

ADVANCES IN KNOWLEDGE

Comparative studies of media contrast safety are scarce and summary information on product characteristics is insufficient. This study showed the differences in severity and profile of adverse reactions between iopromide and iomeprol.

[Hypophosphatemia and chest pain related to adefovir dipivoxil treatment for chronic hepatitis B: report of two cases]

Adefovir dipivoxil (ADV) is an acyclic nucleotide phosphate analogue, currently used for anti-HBV therapy. A few cases of hypophosphatemia related to ADV were reviewed. We report two cases of chronic hepatitis B patients with the chief complaints of chest pain due to hypophosphatemia associated with ADV treatment.

Safety and effectiveness of candesartan and candesartan/HCT fixed dose combination in patients with hypertension

AIM

to assess the safety and effectiveness of candesartan and candesartan/HCT fixed-dose combination (FDC) in patients with hypertension in daily clinical practice.

METHODS

an open observational study with a 12-week period of treatment. Candesartan tablets of 4 mg, 8 mg, or 16 mg, or candesartan/HCT FDC tablets (16/12.5 mg) were prescribed to adult hypertensive subjects, both treatment-naive patients and previously treated but uncontrolled patients, depending on the physicians' discretion based on his/her judgment on the clinical condition.

RESULTS

from a total of 112 treatment-naive patients and 381 previously treated patients eligible for safety analysis, there were only 3 patients with adverse events, and 2 of which were considered possibly related to candesartan (0.41%) and there were no serious adverse events. Both patients were previously treated patients, one patient experienced nausea and the other patient experienced paresthesia. Candesartan and candesartan/HCT were effective in lowering systolic blood pressure (SBP) and diastolic blood pressure (DBP) from baseline at weeks 4, 8, and 12, in both groups, with 26-27 mm Hg decreases in SBP at week 12 and a trend toward a larger reduction in treatment-naive patients than in previously treated patients, although not statistically significant. However, in terms of patients achieving a BP of <140/90 mm Hg between groups were significantly superior in treatment-naive patients than in previously treated patients at week 8 (56% vs 40%; p=0.003) and week 12 (69% vs 53%; p=0.004). Candesartan and candesartan/HCT were also effective for patients with long-standing (>4 years) uncontrolled hypertension with previous antihypertensive therapy, which was most commonly calcium channel blockers (became controlled in >50% of all uncontrolled patients).

CONCLUSION

results of this open observational study showed that candesartan and candesartan/HCT were well tolerated and effective in both treatment-naive patients and uncontrolled hypertensive patients with previous antihypertensive treatment.

Early tolerability and safety of fingolimod in clinical practice

BACKGROUND

Fingolimod is approved by the U.S. Food and Drug Administration to reduce relapses and disability progression in relapsing forms of MS. Several screening studies and a first-dose observation (FDO) period are recommended due to adverse effects observed in clinical trials.

OBJECTIVE

The objective of this study is to describe the early experience with fingolimod, including startup, tolerability and safety in a large academic multiple sclerosis (MS) center.

METHODS

Patients prescribed fingolimod from September 2010 to July 2011 were identified through electronic medical records. Demographics, MS disease history, pre-treatment screening studies, FDO experience during shared medical visits and three month follow-up data were analyzed.

RESULTS

Three hundred ninety-one patients were prescribed fingolimod of whom 317 started the medication and were included in the analysis. Fingolimod was most frequently used in relapsing remitting MS (n=256, 80.8%) and was prescribed as a first-line agent in 11 cases (3.5%). FDO was uneventful in 308 patients (96.8%). Adverse events during FDO were self limited and included symptomatic bradycardia (n=3), chest tightness (n=2) and hypertension (n=1). Fingolimod was discontinued in 30 patients (9.5%) at three months. Adverse effects leading to discontinuation by more than one patient included headache (n=4), macular edema (n=3), nausea (n=3) and hypertension (n=2).

CONCLUSIONS

Fingolimod was well tolerated during FDO and adverse events were self limited. The shared medical visit is an appropriate setting for FDO. Adverse effects were similar to those described in clinical trials but the discontinuation rate was higher.

Assessment of myocardial infarction by CT angiography and cardiovascular MRI in patients with cocaine-associated chest pain: a pilot study

OBJECTIVES

Cocaine is a commonly used illicit drug that leads to the most emergency department (ED) visits. Chest pain is the most common presentation, reported in 40% of patients. Our aim was to evaluate the incidence of previous myocardial infarction among young cocaine users (18-40 years) with cocaine-associated chest pain by the assessment of myocardial fibrosis by cardiovascular MRI. Second, we also intended to evaluate the coronary tree by CT angiography (CTA).

METHODS

24 cocaine users (22 males) who frequently complained about cocaine-associated chest pain underwent CTA and cardiovascular MRI. Mean age of patients was 29.7 years and most of them (79%) had frequently used inhalatory cocaine.

RESULTS

The calcium score turned out to be positive in only one patient (Agatston=54). Among the coronary segments evaluated, only one patient had calcified plaques at the anterior descending coronary artery (proximal and medium segments). Assessment of regional ventricular function by the evaluation of 17 segments was normal in all patients. None of the patients showed myocardial delayed enhancement, indicative of myocardial fibrosis. CTA therefore confirmed the low cardiovascular risk of these patients, since most of them (96%) had no atherosclerosis detected by this examination. Only one patient (4%) had coronary atherosclerosis detected, without significant coronary stenosis.

CONCLUSION

Cardiovascular MR did not detect the presence of delayed enhancement indicative of myocardial fibrosis among young cocaine users with low cardiovascular risk who had complained of cocaine-associated chest pain.

Cohort study on respiratory and neurological disorders among workers in a bone glue factory in Egypt

BACKGROUND

Glues are strong, liquid adhesive derived from animal tissues. It has been shown that glue sniffing is associated with demyelinating polyneuropathy. The low molecular weight agents which cause occupational lung disease have generally included the isocyanates exposure to which could result in asthma among workers. Toluene is also used widely in glue and adhesive industry and households where toluene exposure and abuse can occur.

OBJECTIVE

To study some respiratory and neurological disorders that may arise in workers in a bone glue factory in Queisna industrial zone, Menoufyia governorate, Egypt.

METHODS

In a historical cohort study, the exposed participants (n = 50) were recruited from workers in a bone glue factory in Queisna industrial zone, Menoufyia governorate. The unexposed group was selected from workers' relatives who had never worked in glue industry. All participants completed a pre-designed questionnaire on personal and occupational histories. Pulmonary function tests as well as electromyography (EMG) were performed for all participants. Urinary hippuric acid was also measure in all participants.

RESULTS

The prevalence of cough, asthmatic attacks and paresthesia were significantly higher among exposed than unexposed participants. Abnormal spirometric measurements (particularly towards obstruction), abnormal EMG and positive urinary hippuric acid were significantly more prevalent among exposed than unexposed group.

CONCLUSION

Spirometry and EMG should be included in the periodic medical examination for exposed workers for early detection of respiratory and neurological disorders. Urinary hippuric acid could be a useful indicator of the nerve conduction abnormalities and should be measured periodically for these workers.

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.

Adenosine-induced coronary artery spasm: a case report

OBJECTIVE

To describe an uncommon complication of intravenous adenosine administration.

CLINICAL PRESENTATION AND INTERVENTION

A 41-year-old female patient presented with palpitations due to supraventricular tachycardia. The patient was treated with intravenous adenosine with resolution of the tachycardia. Subsequently, the patient developed chest pain and ST segment elevation in the inferior leads that resolved with sublingual nitroglycerin.

CONCLUSION

This report showed a case of coronary spasm secondary to the administration of adenosine. We therefore recommend that discretion be exercised when giving adenosine, especially to patients with an underlying tendency for vasospastic reactions.

Phenomenology of adolescent inhalant intoxication

Although volatile substance inhalation is prevalent in many contexts and presents a serious threat to public health, this pernicious form of substance misuse remains poorly understood. The question of why people seek and misuse inhalants may be addressed by examining phenomenological accounts of inhalant intoxication, yet few investigations of inhalant intoxication experiences are reported in the literature. This investigation employed a structured interview to assess inhalant intoxication experiences of 267 low-, moderate-, and high-frequency inhalant users. Low-frequency inhalant users reported predominately hedonic experiences during inhalant intoxication, whereas high-frequency users reported a mixture of hedonic and aversive experiences. Aversive experiences such as depressed mood, suicidal ideation, and chest pain were commonly reported by high-frequency users but were relatively rare among low-frequency users. High-frequency users also experienced significantly more euphoria, talkativeness, and grandiosity during inhalant intoxication than low-frequency users. Hedonic and aversive experiences during episodes of inhalant intoxication are relatively common among high-frequency adolescent inhalant users.

Feasibility and safety of high-dose adenosine perfusion cardiovascular magnetic resonance

INTRODUCTION

Adenosine is the most widely used vasodilator stress agent for cardiovascular magnetic resonance (CMR) perfusion studies. With the standard dose of 140 mcg/kg/min some patients fail to demonstrate characteristic haemodynamic changes: a significant increase in heart rate (HR) and mild decrease in systolic blood pressure (SBP). Whether an increase in the rate of adenosine infusion would improve peripheral and, likely, coronary vasodilatation in those patients is unknown. The aim of the present study was to assess the tolerance and safety of a high-dose adenosine protocol in patients with inadequate haemodynamic response to the standard adenosine protocol when undergoing CMR perfusion imaging.

METHODS

98 consecutive patients with known or suspected coronary artery disease (CAD) underwent CMR perfusion imaging at 1.5 Tesla. Subjects were screened for contraindications to adenosine, and an electrocardiogram was performed prior to the scan. All patients initially received the standard adenosine protocol (140 mcg/kg/min for at least 3 minutes). If the haemodynamic response was inadequate (HR increase < 10 bpm or SBP decrease < 10 mmHg) then the infusion rate was increased up to a maximum of 210 mcg/kg/min (maximal infusion duration 7 minutes).

RESULTS

All patients successfully completed the CMR scan. Of a total of 98 patients, 18 (18%) did not demonstrate evidence of a significant increase in HR or decrease in SBP under the standard adenosine infusion rate. Following the increase in the rate of infusion, 16 out of those 18 patients showed an adequate haemodynamic response. One patient of the standard infusion group and two patients of the high-dose group developed transient advanced AV block. Significantly more patients complained of chest pain in the high-dose group (61% vs. 29%, p = 0.009). On multivariate analysis, age > 65 years and ejection fraction < 57% were the only independent predictors of blunted haemodynamic responsiveness to adenosine.

CONCLUSIONS

A substantial number of patients do not show adequate peripheral haemodynamic response to standard-dose adenosine stress during perfusion CMR imaging. Age and reduced ejection fraction are predictors of inadequate response to standard dose adenosine. A high-dose adenosine protocol (up to 210 mcg/kg/min) is well tolerated and results in adequate haemodynamic response in nearly all patients.

Occupational obstructive airway diseases caused by the natural gas odorant tetrahydrothiophene--two case reports

BACKGROUND

Tetrahydrothiophene (THT) is frequently used to odorize natural (city) gas. Only sparse data on adverse health effects of THT on humans are available.

METHODS

We performed a literature search and clinical investigations including case history and cardiopulmonary diagnostic tests in two symptomatic THT-exposed outpatients.

RESULTS

The two THT-exposed city workers developed transient neurologic symptoms such as nausea, vomiting, headaches, as well as skin and mucosa irritation, chronic rhinitis, chronic obstructive pulmonary disease, arterial hypertension, and cardiac arrhythmia. The neurological symptoms and respiratory disorders were found to be caused by intermittently high THT exposures. In favor of a causal relationship were severe work-related neurological and respiratory symptoms in previously healthy workers, results of animal experiments, and another report with very similar findings in the literature. The etiology of arterial hypertension and cardiac arrhythmia, however, remains unclear.

CONCLUSIONS

Our two case reports demonstrate that repeated high THT-exposures can--in addition to neurotoxic symptoms--elicit chronic obstructive pulmonary disease. We recommend improved primary and secondary preventive measures, including the establishment of a TLV.

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.

[Coronary artery disease attack caused by cytotoxic chemotherapy]

Capesitabine is a orally administered cytotoxic drug metabolized to 5-fluorouracil and is widely used in large intestine cancer and breast cancer therapy. Its adverse effects against the heart have been considered to be rare. We describe four patients, who were diagnosed with an attack of coronary artery disease during capesitabine therapy on the basis of coronary spasm. This adverse effect should be kept in mind as a cause of chest pain symptoms and the medication discontinued in a suspected case.

Chest pain without significant coronary stenosis after implantation of sirolimus-eluting stents

We encountered a case of exercise-induced chest pain after the implantation of sirolimus-eluting stents (SESs). She had no history of previous chest pain, and an exercise stress test just after the implantation of the SESs was negative without any symptoms. However, six months after the implantation of the SESs, she began to experience frequent episodes of severe chest pain on effort in spite of there being no significant coronary stenosis. Interestingly, severe coronary vasoconstriction was induced by an intracoronary administration of acetylcholine, and exercise stress testing revealed positive findings with chest pain and ST-T segment depression on ECG. An intensive treatment with two types of calcium channel blockers could readily and completely abolish the exercise-induced chest pain and ST-T segment depression on the ECG. In view of these findings, we presumed that coronary microvessel dysfunction and/or exercise-induced coronary vasoconstriction leading to myocardial ischemia had appeared 6 months after the implantation of the SESs. Although the pathogenesis of this phenomenon could not be completely elucidated, the anatomical and functional abnormalities of the coronary arteries associated with the implantation of the SESs may have been one of the most important mechanisms.

Respiratory symptoms, sensitization, and exposure response relationships in spray painters exposed to isocyanates

RATIONALE

Associations between oligomeric isocyanate exposure, sensitization, and respiratory disease have received little attention, despite the extensive use of isocyanate oligomers.

OBJECTIVES

To investigate exposure-response relationships of respiratory symptoms and sensitization in a large population occupationally exposed to isocyanate oligomers during spray painting.

METHODS

The prevalence of respiratory symptoms and sensitization was assessed in 581 workers in the spray-painting industry. Personal exposure was estimated by combining personal task-based inhalatory exposure measurements and time activity information. Specific IgE and IgG to hexamethylene diisocyanate (HDI) were assessed in serum by ImmunoCAP assay and enzyme immunoassays using vapor and liquid phase HDI-human serum albumin (HDI-HSA) and HSA conjugates prepared with oligomeric HDI.

MEASUREMENTS AND MAIN RESULTS

Respiratory symptoms were more prevalent in exposed workers than among comparison office workers. Log-linear exposure-response associations were found for asthmalike symptoms, chronic obstructive pulmonary disease-like symptoms, and work-related chest tightness (prevalence ratios for an interquartile range increase in exposure of 1.2, 1.3 and 2.0, respectively; P </= 0.05). The prevalence of specific IgE sensitization was low (up to 4.2% in spray painters). Nevertheless, IgE to N100 (oligomeric HDI)-HSA was associated with exposure and work-related chest tightness. The prevalence of specific IgG was higher (2-50.4%) and strongly associated with exposure.

CONCLUSIONS

The results provide evidence of exposure-response relationships for both work-related and non-work-related respiratory symptoms and specific sensitization in a population exposed to oligomers of HDI. Specific IgE was found in only a minority of symptomatic individuals. Specific IgG seems to be merely an indicator of exposure.

Lung abnormalities after dasatinib treatment for chronic myeloid leukemia: a case series

Tyrosine kinase inhibitors have revolutionized the treatment of chronic myeloid leukemia and are increasingly used for other indications. Fluid retention, however, including pleural effusions, are a significant side effect of imatinib, the first-line treatment for chronic myeloid leukemia. We investigated pleural and pulmonary complications in patients treated with dasatinib, a novel multitargeted tyrosine kinase inhibitor, as part of clinical trial protocols. Of 40 patients who received dasatinib (70 mg twice daily) for imatinib resistance or intolerance, 9 (22.5%) developed dyspnea, cough, and chest pain. Of these nine patients, six had pleural effusions (all were exudates) and seven had lung parenchyma changes with either ground-glass or alveolar opacities and septal thickening (four patients had both pleural effusions and lung parenchyma changes). Lymphocytic accumulations were detected in pleural and bronchoalveolar lavage fluids in all patients except for one who presented with neutrophilic alveolitis. Pleural biopsies revealed lymphocytic infiltration in one patient and myeloid infiltration in another. After dasatinib interruption, lung manifestations resolved in all cases and did not recur in three of four patients when dasatinib was reintroduced at a lower dose (40 mg twice daily). Thus, lung physicians should be aware that lung manifestations, presumably related to an immune-mediated mechanism rather than fluid retention, may occur with dasatinib treatment.

Efficacy and tolerability of zolmitriptan oral tablet in the acute treatment of menstrual migraine

OBJECTIVE

To determine the efficacy and tolerability of zolmitriptan 2.5 mg oral tablet as an acute treatment for menstrual migraine attacks.

METHODS

This was a two-phase, multicentre, randomised, double-blind, placebo-controlled, parallel-group outpatient study (Phase I is reported here). The study was conducted at 27 sites in the USA. Eligible women were randomised (1 : 1) to receive either zolmitriptan 2.5 mg oral tablet or placebo, and instructed to acutely treat up to two menstrual migraine attacks per menstrual period for up to three menstrual cycles with a single dose of study medication. Menstrual migraine was operationally defined as an attack occurring within the time period of 2 days prior to the expected onset of menses to 5 days after the onset of menses. Participants were asked to treat migraine headaches of moderate or severe intensity only that occurred >24 hours after the end of the last migraine attack and that had not been acutely treated with other medications. Information regarding each migraine attack was recorded by patients in treatment diary cards. The primary efficacy variable was 2-hour headache response (defined as a 2-point drop on a 4-point scale) for all attacks treated. Secondary variables included 1- and 4-hour headache response rate; 1-, 2- and 4-hour headache response based on a 100 mm visual analogue scale (VAS); pain-free rate at 1, 2 and 4 hours; use of escape medication; the proportion of patients with recurrence within 24 hours of initial treatment; and tolerability.

RESULTS

The intention-to-treat population comprised 334 patients (zolmitriptan [n = 174]; placebo [n = 160]). Patients treated 625 attacks with zolmitriptan and 529 attacks with placebo. Twice as many patients who took zolmitriptan achieved a 2-hour headache response compared with placebo recipients (65.7% vs 32.8%; p < 0.0001). Furthermore, a significantly higher headache response was observed with zolmitriptan than placebo at all timepoints assessed. Significantly more zolmitriptan recipients were pain-free 2 hours post-dose compared with placebo recipients (p < 0.0001). The use of escape medication was considerably lower in zolmitriptan recipients (42.6% vs 71.3%; p < 0.0001). Based on the reduction in VAS score of > or = 30 mm from baseline, significantly more zolmitriptan recipients achieved headache response compared with placebo recipients at 1, 2 and 4 hours post-dose (all p < 0.0001). Recurrence was reported in 29.1% of zolmitriptan-treated attacks versus 45.1% of placebo-treated attacks (p = 0.0009), with median time to recurrence of 8.5 and 4.0 hours, respectively. Zolmitriptan was well tolerated.

CONCLUSION

Oral zolmitriptan is effective and well tolerated for the acute treatment of menstrual migraine attacks. The results are similar to those seen with zolmitriptan in studies of the general migraine population.

Do calcium antagonists contribute to gastro-oesophageal reflux disease and concomitant noncardiac chest pain?

AIMS

A cohort retrospective observational study was undertaken to determine the relationship between calcium antagonist (CA) use and gastro-oesophageal reflux disease (GORD), as well the ability of CAs to precipitate or exacerbate noncardiac chest pain, an atypical symptom of GORD.

METHODS

Eligible patients were those prescribed CAs for hypertension without a history of ischaemic heart disease or nitrate use. Patients were recruited through 15 pharmacies (hospital 1, community 14). Patients giving informed consent were administered a standard questionnaire to obtain information including history of reflux symptoms before and during treatment with CAs, and the management of these symptoms.

RESULTS

Three hundred and seventy-one participants were enrolled. Their mean age was 64 years (SD +/- 12.7 years), 51.2% were females and 48.8% males. Of the 130 patients with pre-existing gastrointestinal (GI) symptoms, 59 (45.4%) reported a worsening of reflux symptoms during CA therapy. Increases in both frequency and severity of symptoms were most common amongst patients on amlodipine (61.3%; P <or= 0.0001) and least common amongst those taking diltiazem (12.5%). Reflux-related symptoms developed in 85 (35.3%) of the 241 previously asymptomatic patients during CA therapy, with verapamil having the greatest number of reports (39.1%; P = 0.001) and diltiazem the least (30.7%).

CONCLUSIONS

Diltiazem appears the least likely of the CAs to precipitate or exacerbate reflux symptoms. Further research using a prospective design could test whether it may be more appropriate to use diltiazem in patients with ischaemic heart disease and could assess the appropriateness of CA therapy in patients with moderate to severe GORD. Increasing prescriber and pharmacist awareness of these adverse effects may result in better patient outcomes and potentially reduce treatment costs.

Methemoglobinemia-induced cardio-respiratory failure secondary to topical anesthesia

Acute toxic methemoglobinemia is an infrequent complication of the use of topical anesthetics, most notably benzocaine. The clinical picture is characterized by sudden development of tissue hypoxia without underlying cardiac or respiratory dysfunction, and deceptively normal oxygen saturation on conventional arterial blood gas analysis. This condition may be rapidly fatal and management depends upon prompt recognition, confirmation of clinical suspicion using cooximetry of arterial blood, and quick institution of therapy. We describe the first reported case of cardio-respiratory failure associated with acute toxic methemoglobinemia, which was initially misconstrued as an evolving acute coronary event and rapidly responded to methylene blue therapy.