Article, Cardiology

Hyperhomocysteinemia-induced myocardial infarction in a young male using anabolic steroids

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American Journal of Emergency Medicine

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Hyperhomocysteinemia-induced myocardial infarction in a young male using anabolic steroids

Abstract

Abuse of androgenic anabolic steroids has been noted to increase the risk for a multitude of cardiac problems, including acute myocardial infarction (MI). A 27-year-old male anabolic steroid user presented to the emergency department with chest pain radiating down his left arm. After initial assessment and electrocardiogram, the patient was diagnosed with an ST-elevation myocardial infarction , and STEMI protocol was initiated. Cardiac catheterization revealed a 70% stenosis of the left anterior descending artery. Further in-patient testing revealed remarkably elevated homocysteine levels, which led to an additional diagnosis of hyperhomocysteinemia. Special attention should be paid to patients who abuse anabolic steroids due to their association with elevated Homocysteine levels and subsequent stenosis of the coronary vessels and MI.

Anabolic steroid use has been shown to have detrimental Cardiac effects including left ventricular hypertrophy, increased thickening of the interventricular septum, dyslipidemia, cardiac arrhythmias, increased blood pressure, and most notably acute myocardial infarctions (MIs) [1-3]. Steroid abuse has become increasingly popular, even transcending the lines of professional athletics to become pervasive at local gyms. Previous cases have reported multiple fatalities from the abuse of anabolic steroids [4,5] as well as numerous incidents of acute MI [6-8]. Furthermore, anabolic steroids have been linked to changes in homocysteine with increases so severe some patients develop hyperhomocysteinemia [9]. Ad- vanced research suggests that increased levels of homocysteine, including mild hyperhomocysteinemia, can lead to atherosclerosis of the coronary vessels as a result of damage to the endothelium and can be considered a risk factor for arterial vascular disease [10]. A previous study showed that bodybuilders chronically taking anabolic steroids developed acute hyperhomocysteinemia [11]. More research still needs to be conducted on the mechanism in which increased levels of homocysteine affect coronary vessels. We report the first case of a patient presenting to the emergency department (ED) with an acute MI due to anabolic steroids and associated elevated homocysteine levels.

We present the case of a 27-year-old, previously healthy male who presented to the ED with substernal chest pain. The patient complained of substernal pressure radiating on the left side of his chest to his left shoulder and down his left arm. The chest pain began promptly after Jujitsu practice. He fell to his knees from the pain and became diaphoretic. Review of systems and medical history was unremarkable. He denied any family history of cardiac problems. He was on no medications but did admit to intermittent anabolic steroid

use. The most recent use was 3 days before his visit. An electrocar- diogram (ECG) was ordered on arrival and showed 1 mm of ST elevation in several leads (see Fig. 1). basic metabolic profile was unremarkable. Cardiac marker laboratories were ordered, which revealed a creatine kinase elevated at 408 U/L and a troponin elevated at 0.14 ng/mL. Interventional cardiology was consulted after the first ECG, and the patient was given 325 mg of aspirin and three 0.4 mg sublingual nitroglycerin. The patient had worsening chest pain, became diaphoretic, and a repeat ECG showed an ST elevation in the anterior leads, I, aVL, and ST depression in lead III (see Fig. 2). An ST-elevation myocardial infarction was called, and the patient was administered 4000 U of heparin and 600 mg of Plavix. He was transferred for cardiac catheterization, which revealed moderate single-vessel coronary artery disease, 70% stenosis of the mid-left anterior descending artery, and a thrombus. His ejection fraction was 45%. Additional tests showed remarkably elevated homocysteine levels of 45.2 umol/L (3.7-13.9 umol/L).The patient was transferred to the cardiovascular intensive care unit. Two days later, he had an echocardiogram, which showed an ejection fraction of 57%. Hematology was consulted for the hyperhomocystei- nemia, and the patient was given folic acid, B6, and B12 supplements. The patient was discharged after 3 days.

The use of anabolic steroids is becoming increasingly popular,

especially among athletes who are looking to increase strength and muscle mass. Roughly 3 million Americans are estimated to take anabolic steroids, a number that is most likely inaccurate due to the stigma of admitting to anabolic steroid use [12]. It has been previously reported that abuse of anabolic steroids has deleterious heath consequences, especially cardiac problems [1-11]. Detrimen- tal cardiac events include arrhythmias, cardiac hypertrophy, and acute MIs [1-9]. The abuse of anabolic steroids has also been linked to increased levels of homocysteine [11]. Furthermore, abnormally high levels of homocysteine have been shown to cause coronary atherosclerosis among many other negative effects [10]. Our patient was found to have markedly high homocysteine levels (45.2 umol/L) after anabolic steroid use. He was diagnosed with a STEMI, and further cardiac testing revealed a 70% stenosis of his LAD with thrombus. To our knowledge, there has never been a case reported of a patient with a STEMI and hyperhomocysteine- mia while taking anabolic steroids. This case is noteworthy because homocysteine levels should be considered when patients admit to anabolic steroids.

Abuse of anabolic steroids has significant detrimental effects on

cardiac health, most notably potential MI. Elevated homocysteine levels with potential stenosis and thrombosis of coronary vessels should be considered.

0735-6757/(C) 2014

Fig. 1. First ECG with ST elevation.

Fig. 2. Repeat ECG showing STEMI.

Kristin Peoples, DO Daniel Kobe, BS Christina Campana, DO

Emergency Department, Akron General Medical Center

Akron, OH, 44307, USA

E-mail address: [email protected]

Erin Simon, DO

Emergency Medicine, Akron General Medical Center

Akron, OH 44307, USA

http://dx.doi.org/10.1016/j.ajem.2014.01.041

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