Substance Misuse and The Heart. Rory O Hanlon ICGP November 2011

Transcription

1 Substance Misuse and The Heart Rory O Hanlon ICGP November 2011

2 Causes of Sudden Death or Acute Cardiac Syndromes Direct effect of the drug Coronary spasm/thrombus Sympathomimetic effects and arrhythmia Catecholamine effects on myocardium QTc prolongation and Torsades Drug effects in underlying cardiomyopathy/qt syndrome

3 Hypotheses 1. Congenital long QT Syndrome 2. Acquired prolonged QT syndrome 3. Arrhthmias secondary to electrolyte imbalance 4. Hypoxia driven EMD/asystole

4 Why CMR? CMR is non-invasive No radiation Non toxic contrast media One stop shop technique Avoids need for multiple other investigations Serial follow up over time

5 Diastology/Strain Ischaemia Proximal Coronaries Myocardial Iron Myocardial Oedema Valve Assessment Scar/Fibrosis Imaging

6 Gadolinium Contrast Unable to penetrate intact myocyte Uptake into extracellular water and if cell membrane injured Inflammation Uptake in regions of fibrosis Infarction Cardiomyopathy

7 Causes of SCD in the young

8 Chest pain, elevated TnI and CK, normal angiogram

9 Investigations High TnI level Direct to cath lab- normal coronary angiogram Normal echocardiogram What s the diagnosis?

10 Cardiac MRI Acute oedema Myocardial scarring/fibrosis

11 Cathinone derivative from the leaves of the Khat plant (Catha Edulis) Traditionally chewed by some African tribes Chemical structure analogous to many amphetamines: MDMA, ecstasy etc.

12 Commonly sold in powder or capsule form Snorted or swallowed While relatively new, a previous case report has documented sympathomimetic effects 1 1: Recreational Use of 4-Methylmethcathinone (4-MMC) Presenting with Sympathomimetic Toxicity and Confirmed by Toxicological Screening - Wood DM, Davies S, Puchnarewicz M, Button J, Archer R, Ramsey J, Lee T, Holt DW, Dargan PI - Clinical Toxicology vol. 47 no

13 It would appear so several deaths in the UK have been linked to the substance but there is also an element of media hysteria.

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15 29 year old mature student, cannabis user, and regular use of head shop products Diagnosis: MYOCARDITIS

16 Methadone

17 METHADONE QT PROLONGATION

18 METHADONE QT PROLONGATION OBTAIN BASELINE ECG FOR ALL PATIENTS AND RISK STRATIFY ACCORDING TO QT C INTERVAL USE WITH CAUTION.. IN PATIENTS AT RISK FOR QT C PROLONGATION MEDICATIONS KNOWN TO PROLONG THE QT C INTERVAL HISTORY OF CONDUCTION ABNORMALITIES. QT C INTERVAL PROLONGATION AND TORSADE DE POINTES MAY BE ASSOCIATED WITH DOSES >100 MG/DAY, BUT HAVE ALSO BEEN OBSERVED WITH LOWER DOSES.

19 A sobering thought

20 Methadone Use Increasingly used as a painkiller Deaths due to methadone (UK) 786 in in prescriptions in 1998 increasing to 4.1 million in 2006.

21 42 yr old alcoholic, ex IVDU, Methadone Episodes of agitation, myoclonic jerks Agitated with brief episodes of depressed GCS Looks like withdrawal

22 167 hospitalized patients methadone maintenance 16% had a prolonged QTc above 500 msec 3.6% had torsades de pointe Arrhythmia was often associated with other risk factors, such as inhibitors of cytochrome P450, hypokalemia, abnormal liver function tests, and a prolonged QTc at baseline. Ehret GB. AIM 2006

23 Patients should be informed of the risk of arrhythmia when they are prescribed methadone. Ask about a history of structural heart disease, arrhythmia, or syncope. Pretreatment ECG to measure the QTc interval. A follow-up ECG should be obtained within 30 days of treatment and annually; additional ECG monitoring is indicated for doses 100 mg per day.

24 Risks and benefits of methadone therapy should be discussed for QTc interval >450 msec but <500 msec, and the ECG monitored more frequently. For QTc interval >500 msec consider discontinuing or reducing the methadone dose; contributing factors (eg hypokalemia, other drugs) should be eliminated and alternative therapy considered.

25 Cocaine

26 Cocaine Use 14% of US population aged 12 and over have tried Cocaine at least once. Intracoronary thrombus Platelet hyperaggregabilty due to increased thromboxane Coronary vasospasm US Department of Health and Human Services: Substance Abuse and Mental Health Services Administration. Results from the 2005 National Survey on Drug Use and Health: National Findings. September 2006.

27 CARDIOVASCULAR CONDITIONS ASSOCIATED WITH COCAINE USE MYOCARDIAL ISCHEMIA OR INFARCTION MYOCARDITIS CARDIOMYOPATHY ARRHYTHMIAS CORONARY ARTERY ANEURYSM FORMATION AORTIC DISSECTION

28 Normal echo and ECG Normal biomarkers 30 cocaine addicts 83% had abnormal CMR 53% were polydrug addicts

29 MYOCARDIAL INFARCTION UNRELATED TO THE DOSE OR FREQUENCY OF USE ONLY 6% OF PATIENTS WITH CHEST PAIN AND RECENT COCAINE USE SUSTAIN AN MI APPROXIMATELY ONE-HALF OF PATIENTS WHO PRESENT WITH COCAINE-RELATED MI HAVE HAD PREVIOUS EPISODES OF CHEST PAIN COCAINE-ASSOCIATED MI IS PARTICULARLY PREVALENT IN YOUNGER PATIENTS IN A REPORT FROM THE THIRD NATIONAL HEALTH AND NUTRITION EXAMINATION SURVEY (NHANES) OF 10,085 ADULTS BETWEEN THE AGE OF 18 AND 45, APPROXIMATELY 25 PERCENT OF NONFATAL MIS WERE ATTRIBUTABLE TO FREQUENT COCAINE USE

30 MYOCARDIAL INFARCTION MI IS USUALLY TEMPORALLY RELATED TO COCAINE USE APPROXIMATELY TWO-THIRDS OF INFARCTIONS OCCURRED WITHIN THREE HOURS OF COCAINE USE APPROXIMATELY 25 PERCENT OCCURRED WITHIN 60 MINUTES AFTER COCAINE USE THE RISK OF A MI WAS 24 TIMES GREATER THAN THE BASELINE RISK DURING THE INITIAL 60 MINUTES AFTER COCAINE INGESTION AND DECREASED PROGRESSIVELY THEREAFTER

31 MYOCARDIAL INFARCTION MOST COCAINE-ASSOCIATED MIs OCCUR IN THE ABSENCE OF HIGH GRADE ATHEROSCLEROTIC CORONARY ARTERY STENOSES IN A REPORT OF 92 PATIENTS WITH COCAINE-ASSOCIATED MI WHO UNDERWENT CORONARY ANGIOGRAPHY, 38% WERE CONSIDERED TO HAVE NORMAL CORONARY ARTERIES AMONG THESE PATIENTS, THE ANTERIOR WALL WAS THE SITE OF INFARCTION IN 77%

32 COCAINE CORONARY ARTERY ANEURYSM CORONARY ARTERY ANEURYSMS CAN BE A POTENTIAL CAUSE OF MYOCARDIAL INFARCTION CORONARY ARTERY ANEURYSMS ARE RELATIVELY COMMON IN COCAINE USERS WHO UNDERGO ANGIOGRAPHY 30% vs. 1.5%

33 18 year old female with TnI + Chest pain Normal angiogram Normal CTPA Normal ECG and echocardiogram Had taken cocaine >48 hrs previously Had chest pain during the night but thought nothing of it. What s the diagnosis? What do we tell the patient happened? Any follow up?

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35 39 Yr old male, chest pain, abnormal ecg, elevated troponin, normal angiogram

36 39 Yr old athlete, chest pain, abnormal ecg, elevated troponin, normal angiogram

37 41 year old female Ex IVDU Smoker and occasional cannabis Partner overdose and RIP Relapses and injects heroin x 1 Presents with chest pain, abnormal ECG, normal coronary angiogram

38 COCAINE MYOCARDITIS & CARDIOMYOPATHY MYOCARDITIS IS A COMMON AUTOPSY FINDING AMONG SUBJECTS DYING FROM COCAINE ABUSE, AFFECTING AS MANY AS 20 TO 30 PERCENT OF PATIENTS THE PRECISE MECHANISM OF THE MYOCARDITIS IS NOT CLEAR HYPOTHESES RANGE FROM HYPERSENSITIVITY REACTIONS LEADING TO VASCULITIS AND MYOCARDITIS TO CATECHOLAMINE- INDUCED TOXICITY

39 COCAINE MYOCARDITIS & CARDIOMYOPATHY COCAINE-INDUCED MYOCARDITIS MAY BE FULLY REVERSIBLE IF IDENTIFIED EARLY IN THE DISEASE PROCESS PATIENTS WITH AN ACUTE EPISODE OF MYOCARDITIS SHOULD BE MANAGED IN A SIMILAR FASHION TO PATIENTS WITH NON- COCAINE-ASSOCIATED MYOCARDITIS ONE NOTABLE EXCEPTION IS THAT DRUGS WITH BETA RECEPTOR BLOCKING PROPERTIES SHOULD BE AVOIDED IN COCAINE USERS

40 HEROIN & MORPHINE

41 HEROIN & MORPHINE ARRHYTHMIA DRUG INDUCED BRADYCARDIA ALONG WITH ENHANCED AUTOMATICITY CAN PRECIPITATE: AN INCREASE IN ECTOPIC ACTIVITY ATRIAL FIBRILLATION IDIOVENTRICULAR RHYTHM OR POTENTIALLY LETHAL VENTRICULAR TACHYARRHYTHMIAS

42 HEROIN & MORPHINE PULMONARY OEDEMA OVERDOSE OF NARCOTIC ANALGESICS CAN CAUSE ACUTE PULMONARY OEDEMA, THE ONSET OF WHICH MAY BE DELAYED FOR UP TO 24 HOURS AFTER ADMISSION

43 Conclusion High prevalence of cardiac damage in cocaine users OTC products and increasing cardiac events Cardiac events in structurally and electrically normal hearts vs. Undiagnosed cardiomyopathy or ion channelopathy Methadone and QTc monitoring CMR not an appropriate screening tool If concerning symptoms despite normal tests For any acute cardiac admission

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