Myocardial injury during standard treatment of an adult with status asthmaticus

Status asthmaticus complicated by cardiac arrest

In the setting of severe acute asthma, electrocardiographic abnormalities are not uncommon and some patients will develop reversible systolic dysfunction. However acute myocardial infarction and potentially fatal arrhythmias are rare. We report the case of a middle-aged indigenous male who suffered an ST-elevation myocardial infarction and then pulseless ventricular tachycardia arrest while still in the acute phase of treatment for status asthmaticus.

Transient ventricular dysfunction after an asphyxiation event: stress or hypoxia?

OBJECTIVE

This report of a pediatric patient with acute upper airway obstruction causing asphyxiation emphasizes the need to maintain clinical suspicion for acquired myocardial dysfunction, despite the presumed role of noncardiogenic causes for pulmonary edema after an acute upper airway obstruction.

DESIGN

Case report.

SETTING

A tertiary pediatric intensive care unit.

PATIENT

A 10-year-old girl with no significant medical history who developed flash pulmonary edema and acute myocardial dysfunction after an acute upper airway obstruction.

INTERVENTIONS

Serial echocardiograms, exercise stress test, and coronary angiography were performed. Serial pro-brain natriuretic peptide, troponins, and CK-MB levels were also followed.

RESULTS

Troponin level normalized approximately 7 days after the acute event. CK-MB and pro-brain natriuretic peptide levels decreased but had not completely normalized by time of discharge. The patient was discharged home 10 days after the event on an anticipated 6-month course of metoprolol without any signs or symptoms of cardiac dysfunction.

CONCLUSIONS

Myocardial dysfunction is rarely documented in children after an acute upper airway obstruction or an asphyxiation event. Pediatric intensivists and hospitalists should maintain a high degree of clinical suspicion and screen for possible myocardial dysfunction in the pediatric patient with an acute severe hypoxic event especially when accompanied by pulmonary edema. Prompt evaluation ensures appropriate support. Additionally, some role may exist for early adrenergic receptor blockade.

Cardiovascular morbidity and the use of inhaled bronchodilators

We used the Manitoba Health database to examine the relationship between use of inhaled respiratory drugs in people with chronic obstructive respiratory diseases and cardiovascular hospitalizations from 1996 through 2000. The drugs examined were beta agonists [BA], ipratropium bromide IB, and inhaled steroids (ICS). End points were first hospitalizations for supraventricular tachycardia, myocardial infarction, heart failure or stroke. A nested case control analysis was employed comparing people with and without cardiovascular events. Cases and controls were matched for gender and age, and conditional logistic regression was used in multivariate analysis considering other respiratory drugs, respiratory diagnosis and visit frequency, non-respiratory, non-cardiac comorbidities, and receipt of drugs for cardiovascular disease. In univariate analyses, BA, IB and ICS were all associated with hospitalizations for cardiovascular disease, but in multivariate analyses ICS did not increase risk while both BA and IB did. There were interactions between respiratory and cardiac drugs receipt in that bronchodilator associated risks were higher in people not taking cardiac drugs; this was especially true for stroke. There were strong interactions with specific cardiac drugs; for example, both BA and IB substantially increased the risk of supraventricular tachycardia in patients not anti-arryhthmic agents, but not in the presence of such agents. We conclude that bronchodilator therapy for chronic obstructive diseases is associated with increased cardiovascular risk, especially in patients without previous cardiovascular diagnoses, and that this is unlikely due to the severity of the respiratory disease, since risk was not increased with ICS.

Acute myocardial infarction and status asthmaticus: a case report

A patient with a painless, extensive anterolateral myocardial infarct, which occurred during a prolonged bout of refractory asthma, is presented. Cardiac catheterization revealed a large akinetic area involving the septum and anterolateral walls and completely normal coronary arteries. The etiology of the infarct was believed to be intense coronary vasospasm occurring during the lengthy period of status asthmaticus.

Acute Myocardial Infarction Associated with Albuterol

OBJECTIVE

To report a case of acute myocardial infarction (AMI) following the use of albuterol (salbutamol) in a patient without preexisting coronary artery disease and to review the related literature.

CASE SUMMARY

An 84-year-old white woman with no history of cardiac disease was treated for an exacerbation of chronic obstructive pulmonary disease with albuterol 5 mg and ipratropium bromide 500 μg nebulized with oxygen; the albuterol was given in the same dose every 2 hours. Her respiratory condition improved, but soon after the sixth dose of albuterol, she developed increasing chest tightness. The electrocardiogram (ECG) showed ST segment elevation in the chest leads (V2,3) and, subsequently, the troponin I concentration and creatine kinase rose. Urgent coronary angiography showed smooth coronary arteries with no obstructive coronary artery disease or thrombosis. Left ventriculography showed anterior hypokinesia consistent with anterior myocardial injury. A subsequent echocardiogram also revealed normal left ventricular size but anterior, anteroseptal, and apical hypokinesia. An objective causality assessment revealed that albuterol had a probable likelihood of causing the AMI in this patient.

DISCUSSION

A MEDLINE search (1966–February 2004) revealed 6 other case reports of AMI associated with albuterol treatment. The possible pathogenesis of albuterol-induced myocardial necrosis includes activation of cardiac and peripheral β2-adrenoceptors, inducing positive chronotropic and inotropic effects and vasodilation with coronary blood flow redistribution. Albuterol can also cause hypokalemia and other metabolic and electrical changes, including prolonged QT interval. These effects may be especially detrimental in patients with hypoxia, hypercapnea, and preexisting heart diseases.

CONCLUSIONS

Although myocardial injury is a rare complication following albuterol therapy, clinicians should use high-dose β2 agonists with caution. Close monitoring of ECG and metabolic changes is recommended before early repeated high doses are administered.