Myocardial injury in a 41-year-old male treated with methylphenidate: a case report

Abstract

BackgroundElevated cardiac troponin levels are consistent with the diagnosis of an acute coronary syndrome, but may also represent adverse drug reactions. Psychostimulating drugs raise both blood pressure and heart rate, and case reports of sudden death, stroke, and myocardial infarction have led to regulatory and public concern about the cardiovascular safety of these drugs.Case presentationWe present a case where a 41-year-old Norwegian male with radiating chest pain, elevated troponins, and supraventricular tachycardia was hospitalized. Tentative diagnosis was acute coronary syndrome. Percutaneous coronary angiography, but not cardiac magnetic resonance imaging, was performed and medical antiplatelet treatment started. Because of an attention deficit/hyperactivity disorder the patient had recently increased his dose of methylphenidate, but still within the therapeutic dose range. Apart from venlafaxine, also in a therapeutic dose, the patient took no other drugs. An acute coronary syndrome was excluded during hospitalization, and a drug effect was suspected.ConclusionsWhen interpreting troponin results it is important to take into account the context of the patient’s clinical presentation, including the possibility of adverse drug reactions. The adverse drug reaction could include a combination of vasospasm and/or increased oxygen demand due to tachycardia. This case should be borne in mind before a diagnosis of myocardial infarction is given, or a decision to perform invasive coronary angiography is made in patients that use methylphenidate or related substances. Cardiac magnetic resonance imaging could be of diagnostic value in such cases.

Association between methylphenidate and risk of myocardial infarction: A multinational self‐controlled case series study

“…Owing to its various uses, there is a trend of increased methylphenidate use across all ages 2 . However, concerns of myocardial infarction following its use continue to be debated 7–9 with case reports reported for children/adolescents, 10,11 adults, 12–16 and the elderly 17 . Although the mechanism for an association has yet to be elucidated, the risk of myocardial infarction may be due to the cardiopressor dopaminergic/noradrenergic effects of methylphenidate that result in increased heart rate and blood pressure 18,19 …”

Methylphenidate-associated chest pain in a child

“…Other studies reported that methylphenidate may induce coronary spasm, causing ST-elevation MI, reduce left ventricular function,17 cause acute MI,18 and rarely, cause pericarditis and cardiomyopathy among long-term users 19. In adults, using methylphenidate is associated with acute MI20 21 and a 1.8-fold increase in the risk of ventricular arrhythmia 13. Although MI is generally rare among children and adolescents, this has been reported in a child with ADHD with comorbid Tourette syndrome 18.…”

Elevation Mechanisms and Diagnostic Consideration of Cardiac Troponins under Conditions Not Associated with Myocardial Infarction. Part 2

“…The acute coronary syndrome was ruled out by coronary angiography. Considering the mechanism of action of this medication, the authors suggested the temporary occurrence of vasoconstriction of the coronary arteries against the background of tachycardia of increased myocardial oxygen demand [94].…”