Article, Cardiology

Does an energy drink cause a transient ischemic attack?

Unlabelled imageCase Report

Does an energy drink cause a transient ischemic attack?

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American Journal of Emergency Medicine

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Abstract

Energy drinks have become a popular beverage especially among Young individuals. The growing literature sheds light on acute health problems associated with these products, although they have not yet been in existence long enough to build a solid, evidence-based appreciation of potential Long-term effects. Perhaps the greatest concern about energy drinks is the amount of caffeine they contain, which generally far exceeds that in other beverages. A Transient ischemic attack has been traditionally defined as an episode of Neurologic dysfunction caused by focal cerebral ischemia with Complete recovery within 24 hours. We report a patient who had a TIA after intake of an energy drink without alcohol. To the best of our knowledge, the following case is the first report of TIA after intake of an energy drink.

A Transient ischemic attack has been traditionally defined as an episode of neurologic dysfunction caused by focal cerebral ischemia with complete recovery within 24 hours [1]. Transient ischemic attack stroke risk is different for each individual based on his or her modifiable (high blood pressure, diabetes, abnormal blood lipid profile, smoking status, sedentary lifestyle, and obesity) and non- modifiable (age, sex) risk factors [2]. The Short-term risk of an ischemic stroke after a TIA is estimated to be approximately 3% to 10%, 5%, and 9% to 17% in the following 2 days, 7 days, and 90 days, respectively, depending on active or passive ascertainment of ischemic stroke.

Energy drinks have become a popular beverage especially among young individuals and are marketed to college students, athletes, and active individuals between the ages of 21 and 35 years. More than half of college students surveyed reported drinking at least 1 energy drink per month [3]. Energy drinks typically contain high levels of caffeine, sugar, and other ingredients such as taurine, B-complex vitamins, ginseng, and guarana seed extract [4].

The growing literature sheds light on acute health problems associated with these products, although they have not yet been in existence long enough to build a solid, evidence-based appreciation of potential long-term effects. Perhaps the greatest concern about energy drinks is the amount of caffeine they contain, which generally far exceeds that in other beverages. Energy drinks may contain more than 500 mg of caffeine per serving, whereas a cup of coffee has 75 to 150 mg of caffeine, and a typical Coke has only 35 mg. Some of the additional herbs such as guarana also contain caffeine. Therefore, the amount of caffeine listed on the label can be less than what is actually present in the drink. The effects of drinking large amounts of caffeine range from anxiety, insomnia, and tachycardia to acute caffeine intoxication and Withdrawal symptoms [4]. Recent reports suggest that these drinks may be associated with cerebral vasculopathy, acute mania, seizures, ischemic stroke, coronary artery vasospasm, acute

coronary Artery thrombosis, cardiac arrest, myocardial infarction, hypertension, and some other severe cases [5-8]. We report a patient who had a TIA after intake of an energy drink without alcohol. To the best of our knowledge, the following case is the first report of TIA after intake of an energy drink.

A previously healthy 26-year-old emergency department physi- cian had a sudden-onset loss of vision in his right eye, which disappeared spontaneously after 4 hours. Because he was already in the emergency department when his symptoms started, his arterial blood pressure, pulse rate, and electrocardiography were taken immediately, and they were all normal. His chest x-ray was normal, too. Cardiovascular and respiratory systems were normal on physical examination. He denied excess caffeine or Alcohol intake, fever, infections, cocaine, cannabis, or other drug abuse. He did not have a history of stroke, head trauma, or family history of cerebrovascular disease. His thrombocyte count, blood urea nitrogen, glucose, thyroid hormones, vitamin B12, and homocysteine levels were normal. Computed tomography scan and magnetic resonance imaging of his brain were normal, too. Tests for factors that may play a role in stroke pathophysiology in young patients including Factor V Leiden mutation, protein C, Protein S, antithrombin 3, methylenetetrahydro- folate reductase mutation, human immunodeficiency virus antigen, VDRL rapid plasma reagin, antiphospholipid antibody, antinuclear antibody, antimitochondrial antibody, anti-double-stranded DNA, anticardiolipin IgG, and anticardiolipin IgM were performed, and all of them were normal. Transthoracic and transesophageal echocardi- ography were performed, and no structural cardiac abnormality was found. Bilateral vertebral and carotid artery ultrasonography and Abdominal ultrasonography were normal. Patient took the diagnosis of TIA, and no etiologic factor that might cause that clinical condition could be found by detailed testing for possible factors. Patient had never smoked or used alcohol and any other illicit drugs. His medical history and family history were negative for stroke and any possible risk factors of stroke. When the patient was asked about any kind of unusual intake of any type of substances, it was learned that he had drunk 2 energy drinks (Redbull, Istanbul, Turkey, 250 mL) with an empty stomach to be more active while he was working in the emergency department. Patient was forbidden to drink any energy drinks again. Our patient was a physician. He was fully aware of his symptoms and their duration. In addition, he was in the emergency department when his symptoms began and stayed in the emergency department until his symptoms disappeared. Finally, we suggested that energy drink was responsible from his symptoms after detailed evaluation of all possible etiologic factors.

To the best of our knowledge, this is the first case of TIA secondary

to energy drink intake. Consumption of high-caffeine energy drinks has increased markedly in recent years. Energy drinks are promoted

0735-6757/(C) 2014

for their stimulant effects and claim to offer a variety of benefits including weight loss, increased attention, endurance, and perfor- mance. Most of these claims, however, remain to be unsubstantiated. The most approved effect of caffeine is that it reduces performance decrements due to reduced alertness (eg, in conditions of fatigue or Sleep deprivation) [9]. Besides, it is very easy to access energy drinks, and that condition leads to a danger that is growing day by day. Common use of energy drinks especially alcohol/energy drinks among the young and the adolescent is a really dangerous problem. There are a lot of reports that overdose of energy drinks may cause serious neurologic and cardiac toxicity presenting with hallucinations, seizures, ischemic stroke, hypertension, thrombosis, and even myocardial infarction [4-6,10]. It has been postulated that excessive consumption of caffeine especially in combination with taurine may trigger important cardiovascular events and induce TIA by causing retinal artery vasospasm especially in physiologically predisposed individuals [10]. It is not entirely proven which, if any, of these ingredients are responsible for inducing TIA, although several potential mechanisms, particularly implicating caffeine and taurine, have been suggested. The Cardiovascular effects of caffeine are perhaps the best defined. Its primary pharmacologic effect is the competitive inhibition of adenosine receptors. However, it also induces Catecholamine release, so it also has a positive inotropic effect. It also has a physiologic effect on intracellular concentration of calcium in vascular smooth muscle, potentially inducing retinal artery vasospasm [7]. Consumption of energy drinks may increase the risk of Caffeine overdose in caffeine abstainers as well as habitual consumers of caffeine from coffee, soft drinks, and tea. In addition, our patient was not used to using caffeine regularly. Hence, that condition might cause the effects of caffeine to be more pronounced.

Cardiovascular effects of taurine are less well established, although

there is in vitro evidence that it has inotropic and vascular effects similar to those of caffeine. It is thought that taurine can also potentiate the physiologic actions of caffeine [7]. In addition, a clinical trial showed that administration of taurine led to correction of endothelial dysfunction and improvement in the aggregation of platelets and blood coagulation [11]. We suggest that taurine might play a similar role in our patient’s TIA pathophysiology. Furthermore, ingredients of energy drinks may cause cardiovascular changes characterized by increase in platelet aggregation, impairment of endothelial function, and increase in blood pressure [12,13]. However, this study did not distinguish which component of the energy drink was responsible for these changes, and the effects were only short lived [13].

As a result, all test results associated with possible etiologic factors of ischemic stroke in young patients were negative in our patient. Therefore, we thought that intake of energy drink on an empty stomach may cause TIA. We found only 1 report that may be related to ischemic stroke due to energy drinks [5]. That is a unique case of a patient who had TIA related to intake of an energy drink. Energy drinks are very popular, especially among Young people. Therefore, we want to call attention to adverse effects of energy drinks. Nevertheless, further study is needed to evaluate the accurate central nervous system effects and mechanisms of action of these popular stimulants and how genetic makeup may contribute to susceptibility to TIA and ischemic stroke.

Suber Dikici, MD

Department of Neurology Duzce University School of Medicine

Duzce, Turkey

Ayhan Saritas, MD Department of Emergency Medicine Duzce University School of Medicine

Duzce, Turkey E-mail address: [email protected]

Seyma Kilinc, MD

Department of Neurology Duzce University School of Medicine

Duzce, Turkey

Semih Guneysu, MD Harun Gunes, MD

Department of Emergency Medicine Duzce University School of Medicine

Duzce, Turkey

http://dx.doi.org/10.1016/j.ajem.2014.06.037

References

  1. [No authors listed]Special report from the National Institute of Neurological Disorders and Stroke. Classification of cerebrovascular diseases III. Stroke 1990;21:637-76.
  2. Gupta HV, Farrell AM, Mittal MK. Transient ischemic attacks: predictability of future ischemic stroke or transient ischemic attack events. Ther Clin Risk Manag 2014;10:27-35 [eCollection 2014].
  3. Malinauskas BM, Aeby VG, Overton RF, Carpenter-Aeby T, Barber-Heidal K. A survey of Energy drink consumption patterns among college students. Nutr J 2007;6:35-41.
  4. Seifert SM, Schaechter JL, Hershorin ER, Lipshultz SE. health effects of energy drinks on children, adolescents, and young adults. Pediatrics 2011;127(3):511-28.
  5. Dikici S, Saritas A, Besir FH, Tasci AH, Kandis H. Do energy drinks cause Epileptic seizure and ischemic stroke? Am J Emerg Med 2013;31(1):274.e1-4. http://dx. doi.org/10.1016/j.ajem.2012.05.018.
  6. Benjo AM, Pineda AM, Nascimento FO, Zamora C, Lamas GA, Escolar E. left main coronary artery acute thrombosis related to energy drink intake. Circulation 2012;125(11):1447-8. http://dx.doi.org/10.1161/CIRCULATIONAHA.111.086017.
  7. Scott MJ, El-Hassan M, Khan AA. Myocardial infarction in a young adult following the consumption of a caffeinated energy drink. BMJ Case Rep 2011:1-3. http://dx. doi.org/10.1136/bcr.02.2011.3854 [pii: bcr0220113854].
  8. Usman A, Jawaid A. Hypertension in a young boy: an energy drink effect. BMC Res Notes 2012;5:591-3. http://dx.doi.org/10.1186/1756-0500-5-591.
  9. Bonnet MH, Balkin TJ, Dinges DF, Roehrs T, Rogers NL, Wesensten NJ. The use of stimulants to modify performance during sleep loss: a review by the Sleep Deprivation and Stimulant Task Force of the American Academy of Sleep Medicine. Sleep 2005;28:1163-87.
  10. Sanaei-Zadeh H. Overuse of energy drinks: why death? Am J Emerg Med 2013;31 (12):1713-4. http://dx.doi.org/10.1016/j.ajem.2013.09.009. Epub 2013 Oct 18.
  11. Rukan TA, Mksimovich NE, Zimatkin SM. Morphofunctional state of vessel endothelium at the early stage of cerebral ischemia-reperfusion and the effect of taurin administration. Eksp Klin Farmakol 2013;76(12):8-10.
  12. Sanaei-Zadeh H. With which mechanism the overuse of energy drinks may induce acute myocardial ischemia? Cardiovasc Toxicol 2012;21:273-4 [http://dx.doi.org/ 10.1007/s12012-012-9160-4 Epub ahead of print].
  13. Worthley MI, Prabhu A, De Sciscio P, et al. Detrimental effects of energy drink consumption on platelet and endothelial function. Am J Med 2010;123(2):184-7.

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