Atrial Fibrillation Due to Over The Counter Stimulant Drugs in A Young Adult

Abstract

A previously healthy 25-year-old Caucasian male with past medical history significant only for nephrolithiasis presented to Monmouth Medical Center with complaints of palpitations for the past one day. The patient has no known cardiac history, no other risk factors for atrial fibrillation, non smoker, no illicit drug use, occasional alcohol drinker. Approximately, two days prior to his presentation the patient started consuming an over the counter pre-workout energy supplement . He stated that he had started to consume this supplement for better concentration and to increase his stamina for his workout. On the day of admission, the patient had gone out for a fishing trip in the morning after consuming another two capsules of the same pre-workout supplement. He developed palpitations and shortness of breath at the fishing trip and was concerned about his symptoms. He presented himself to the Emergency Department (ED) for further evaluation and treatment.On admission, he denied any further complaints. His vitals were stable except for his rapid heart rate of 140 bpm which was irregularly irregular. He was not in acute distress and his Electrocardiogram showed atrial fibrillation with rapid ventricular response, rate of 123 bpm, normal axis, and no ST-T wave changes [Table/ Fig-2]. Physical examination was remarkable for were unremarkable, his thyroid functions were in the normal range, urine and serum toxicology screen were negative for any drugs or illicit substances. Concerning the Electrocardiogram and physical examination findings a diagnosis of new onset atrial fibrillation with rapid ventricular response was made.The patient was administered intravenous diltiazem boluses in the ED and was started on a diltiazem infusion for rate control of his atrial fibrillation. Heart rate was continuously monitored on telemetry. The patient eventually converted into normal sinus rhythm, 9 hours after initiation of diltiazem infusion. The patient eventually had an echocardiogram which showed LVEF 66%, normal left ventricular size, trace mitral regurgitation and trace tricuspid regurgitation and no other significant valvular pathology. Given the patient's unremarkable echocardiogram, unremarkable labwork and absent cardiac history along with no other risk factors for atrial fibrillation the cause of his new onset atrial fibrillation was attributed to his consumption of over the counter energy capsules. His CHADS2 VASc score was 0 and hence the patient was eventually discharged home with regular scheduled outpatient follow-up visits. DISCUSSIONOver the counter stimulants are easily available in the form of pills, energy drink, liquid capsules and energy shots. One of the major constituents of these preparations is caffeine. The amount of caffeine present in these over the counter energy supplements are in excess compared to the standard FDA approved guidelines for quantities' of caffeine [Table/ Fig-1]. These are widely aimed at the teenagers and young adults. Several studies suggest that energy drinks may serve as a gateway...

Caffeine intake reduces incident atrial fibrillation at a population level

“…The papers showing a direct caffeine → AF association are anecdotal. 3,17 Other studies emphasise the absence of any effect of caffeine on incident AF in non-population-based 8 and population-based epidemiological setting 18 and in short-term experiments on little numbers of subjects. 19 A neutral role of caffeine emerges from some data pooling 6 or meta-analysis.…”

From Boost to Burden: Investigating Energy Drinks and Myocarditis

“…Over the counter stimulants are easily available in the form of pills, energy drink, liquid capsules and energy shots and there has been an increase in emergency visits involving energy drinks with up to 10% of this cases resulting in hospitalization [4,6,9].…”

“…While some effects caused by energy drinks intake can be reversible, others present life-threatening conditions including atrial brillation [8, 9,20], myocardial infarction [7,8,21], potentially fatal arrhythmias [8, 21,22] and even reports on deaths [5,7,8,11]. Some possible explanations for these events are review by Goldfarb et al [8] and include increase in circulating catecholamine [5,12], additional unaccounted caffeine content [7], increased platelet aggregation and worsen endothelial function [16], as well as caffeine toxicity in naïve consumers [5] and coronary spasm [21].…”

Interaction of Energy Drinks with Prescription Medication and Drugs of Abuse

“…Obesity and hyperinsulinemia have been reported as metabolic adverse effects [22]. Neuropsychiatric adverse effects include epileptic seizures [13,14,24,32,37,40,41], reversible cerebral vasoconstriction [22], intracerebral haemorrhage [13,22], acute psychosis [13,22,37], and risk-taking behaviours [13] (for instance, hazardous driving with excessive speed and seat belt omission [22], sexual risk taking [22], and drug use [41]).…”

“…Its mechanism of action, pharmacokinetics, and effects are therefore similar to those previously described for caffeine (see Section 3.1.1). Guarana intoxication produces water loss, gastric irritation, nausea, vomiting, metabolic acidosis, hyperglycaemia, ketosis, chest pain, syncope, tachydysrhythmia (a risk that is increased in the case of structural heart disease), shortness of breath, insomnia, nervousness, restlessness, tremors, anxiety, mania, seizures, and even sudden death [14,35,41].…”