- Email: [email protected]
Contraindication to thrombolytic therapy in accidental hypothermia simulating acute myocardial infarction
269
Acknowledgement The authors thank MS Karen Shashok the original manuscript into English.
for translating
1 PringIe SD, McCartney AC, Marshall DAS, Cobbe SM. Infective endocarditis caused by Streptococcw agalactiae. Int J Cardiol 1989;24:179-183. 2 Woo KS, Lam YM, Kwok HT. Tse LKK, Valiance-Owen J.
International Elsetier CARD10
Journal of Cardiology,
Prognostic index in prediction of mortality from infective endocarditis. Int J Cardiol 1989;24:47-54. 3 Smyllie JH, Sutherland GR, Roelandt J. Tbe changing role of echocardiography in the diagnosis and management of infective endocarditis. Int J Cardiol 1989;23:291-301. 4 Bisno AL, Dismukes WE, Durak DT et al. Antimicrobial treatment of infective endocarditis due to viridans streptococci, enter-i, and staphylococci. J Am Med Assoc 1989;261:1471-1477. 5 Stein DS, Libertin CR. Antibiotics in endocarditis due to nutritionally deficient streptococci (Letter). J Am Med Assot 1989;262:618.
28 (1990) 269-272
11127
Contraindication to thrombolytic therapy in accidental hypothermia simulating acute myocardial infarction A. Glusman, K. Hasan and N. Roguin Deparlment
of Cardiology,
Western Galilee Regional Hospital, Nahariya, Faculty of Medicine, Technion, Halfa, Israel (Received 1 February 1990; revision accepted 18 March 1990)
A 35-year-old schizophrenic patient was admitted to the Coronary Care Unit with shock, bradycardia and ST-T changes mimicking acute myocardial infarction. The rectal temperature was 33.6 o C and the diagnosis of accidental hypothermia was established. Accidental hypothermia must be considered in the differential diagnosis of acute myocardial infarction before instituting thrombolytic therapy. Key words:
Accidental
hypothermia:
Thrombolytic
therapy
Introduction
cardia
Accidental hypothermia is a well-known complication of prolonged exposure to low environmental temperature and is not uncommon in northern countries during winter, especially in the elderly [l]. It is found in association with myxedema, pituitary insufficiency, Addison’s disease, cerebrovascular accidents and ingestion of drugs or alcohol. Hypothermia has also been described in a schizophrenic patient related to the use of antipsychotic drugs [2]. The purpose of this report is to describe a case of accidental hypothermia in a schi-
Correspondence to: N. Roguin, M.D., Dept. of Cardiology, Western Galilee Regional Hospital. P.O. Box 21, Nabariya, Israel. 0167-5273/90/$03.50
patient
zophrenic
and
myocardial
who
Osbom
(.I)
presented waves
with
shock,
simulating
an
bradyacute
infarction.
Case Report A 35year-old female patient was referred to our Institution with severe hypotension and ST-T changes on the electrocardiogram. She was a heavy smoker, schizophrenic patient, received daily treatment with levopromazine 100 mg, haloperidol 5 mg and flunitrazepam 4 mg. A few days before admission, she developed progressive hypotension, bradycardia, and confusion. All the medications were stopped. In the emergency room, an electrocardiogram showed sinus bradycardia at a rate of 46 beats per minute with an abnormal ST-T segment (Fig. 1). The patient was admitted to the
0 1990 Elsevier Science Publishers B.V. (Biomedical Division)
Fig. 1. Electrocardiogram
in the coronary
care unit. A. Frontal leads. B. Precordial anterolateral wall.
Coronary Care Unit. She was pale and confused, with muscular rigidity and tremors. The pulse was weak (46 per minute) and the blood pressure was 60/30. There
leads. J waves (Osbom)
in diaphragmatic
and
were no murmurs nor friction rubs. No jugular venous engorgement and no edema were seen and the lungs were clear. The liver was not palpable. With a conven-
Fig. 2. Electrodiagram 24 hours later, the J waves have disappeared. tional thermometer, the rectal temperature was 35’C. The electrocardiogram (Fig. 1) showed sinus bradycardia at 46 beats per minute, a PR interval of 0.16 set, normal QRS complexes and J waves (Osbom waves). The chest X-ray was normal. Echocardiography showed normal contractility and no pericardial effusion. An hour later, the rectal temperature was 33.6OC. The diagnosis of accidental hypothermia was established. She was rewarmed with blankets, and intravenous fluid was given with sympathomimetic support, potassium and antibiotics. After 24 hours she was conscious, the pulse had risen to 70 per minute, the blood pressure was 100/70 and there was good urinary output. The electrocardiogram had returned to normal, the J waves disappeared and the ST segment showed a normal aspect (Fig. 2). The patient then complained of abdominal pain and radiography showed mild ileus. Levels of amylase in the serum were 3000 units and, for urinary diastase, 16000 units. The cardiac enzymes were normal. Glucose, measured at 327 mg/dl of blood, returned to normal without treatment. Acute pancreatitis was diagnosed. The patient was discharged four days after admission in good clinical condition. Discussion A distinctive J deflection (or Osbom wave) is known to occur at the junction of the QRS complex and ST
segment in accidental hypothermia. This wave was present in 11 of 19 patients described by Duguid et al. [l]. In our patient, the wave was so marked that, in the emergency room, the diagnosis of acute myocardial infarction was considered. Two patients have recently been reported [2] who received thrombolysis for cardiovascular conditions mimicking acute myocardial infarction: namely, pericarditis and thoracic aortic dissection. Both patients required surgery and one died. Thrombolytic therapy in patients with evolving acute myocardial infarction improves survival. The impact of reperfusion is critically dependent on how early it is achieved. Keren et al. [3] advocate the use of thrombolytic therapy even in the patient’s home or in the ambulance on the way to the hospital. In patients dying from accidental hypothermia, however, hemorrhagic changes have been noted in the pancreatic tissues. The use of thrombolytic therapy, therefore, could produce serious complications in these patients. Accidental hypothermia must always be considered in the differential diagnosis of acute myocardial infarction before thrombolytic therapy is given. References 1 Duguid H, Simpson RG, Stowers JM. Accidental hypothermia. Lancet 1961;1214-1219. 2 Noto T, Hashimoto H, Sugai S, et al. Hypothermia caused
212
by antipsychotic drugs in a schizophrenic patient. J Clin Psychiat 1987;48:77. 3 Blankenship JC, Almquist AK. Cardiovascular complications of thrombolytic therapy in patients with a mistaken diagnosis of acute myocardial infarction. J Am Co11 Cardiol 1989;14:1579-1582.
4 Keren G, Weiss AT, Hasin Y, et al. Prevention of myocardial damage in acute myocardial ischemia by early treatment with intravenous streptokinase. N Engl J Med 1985;313: 1384-1389.
Acknowledgement The authors thank MS Karen Shashok the original manuscript into English.
for translating
1 PringIe SD, McCartney AC, Marshall DAS, Cobbe SM. Infective endocarditis caused by Streptococcw agalactiae. Int J Cardiol 1989;24:179-183. 2 Woo KS, Lam YM, Kwok HT. Tse LKK, Valiance-Owen J.
International Elsetier CARD10
Journal of Cardiology,
Prognostic index in prediction of mortality from infective endocarditis. Int J Cardiol 1989;24:47-54. 3 Smyllie JH, Sutherland GR, Roelandt J. Tbe changing role of echocardiography in the diagnosis and management of infective endocarditis. Int J Cardiol 1989;23:291-301. 4 Bisno AL, Dismukes WE, Durak DT et al. Antimicrobial treatment of infective endocarditis due to viridans streptococci, enter-i, and staphylococci. J Am Med Assoc 1989;261:1471-1477. 5 Stein DS, Libertin CR. Antibiotics in endocarditis due to nutritionally deficient streptococci (Letter). J Am Med Assot 1989;262:618.
28 (1990) 269-272
11127
Contraindication to thrombolytic therapy in accidental hypothermia simulating acute myocardial infarction A. Glusman, K. Hasan and N. Roguin Deparlment
of Cardiology,
Western Galilee Regional Hospital, Nahariya, Faculty of Medicine, Technion, Halfa, Israel (Received 1 February 1990; revision accepted 18 March 1990)
A 35-year-old schizophrenic patient was admitted to the Coronary Care Unit with shock, bradycardia and ST-T changes mimicking acute myocardial infarction. The rectal temperature was 33.6 o C and the diagnosis of accidental hypothermia was established. Accidental hypothermia must be considered in the differential diagnosis of acute myocardial infarction before instituting thrombolytic therapy. Key words:
Accidental
hypothermia:
Thrombolytic
therapy
Introduction
cardia
Accidental hypothermia is a well-known complication of prolonged exposure to low environmental temperature and is not uncommon in northern countries during winter, especially in the elderly [l]. It is found in association with myxedema, pituitary insufficiency, Addison’s disease, cerebrovascular accidents and ingestion of drugs or alcohol. Hypothermia has also been described in a schizophrenic patient related to the use of antipsychotic drugs [2]. The purpose of this report is to describe a case of accidental hypothermia in a schi-
Correspondence to: N. Roguin, M.D., Dept. of Cardiology, Western Galilee Regional Hospital. P.O. Box 21, Nabariya, Israel. 0167-5273/90/$03.50
patient
zophrenic
and
myocardial
who
Osbom
(.I)
presented waves
with
shock,
simulating
an
bradyacute
infarction.
Case Report A 35year-old female patient was referred to our Institution with severe hypotension and ST-T changes on the electrocardiogram. She was a heavy smoker, schizophrenic patient, received daily treatment with levopromazine 100 mg, haloperidol 5 mg and flunitrazepam 4 mg. A few days before admission, she developed progressive hypotension, bradycardia, and confusion. All the medications were stopped. In the emergency room, an electrocardiogram showed sinus bradycardia at a rate of 46 beats per minute with an abnormal ST-T segment (Fig. 1). The patient was admitted to the
0 1990 Elsevier Science Publishers B.V. (Biomedical Division)
Fig. 1. Electrocardiogram
in the coronary
care unit. A. Frontal leads. B. Precordial anterolateral wall.
Coronary Care Unit. She was pale and confused, with muscular rigidity and tremors. The pulse was weak (46 per minute) and the blood pressure was 60/30. There
leads. J waves (Osbom)
in diaphragmatic
and
were no murmurs nor friction rubs. No jugular venous engorgement and no edema were seen and the lungs were clear. The liver was not palpable. With a conven-
Fig. 2. Electrodiagram 24 hours later, the J waves have disappeared. tional thermometer, the rectal temperature was 35’C. The electrocardiogram (Fig. 1) showed sinus bradycardia at 46 beats per minute, a PR interval of 0.16 set, normal QRS complexes and J waves (Osbom waves). The chest X-ray was normal. Echocardiography showed normal contractility and no pericardial effusion. An hour later, the rectal temperature was 33.6OC. The diagnosis of accidental hypothermia was established. She was rewarmed with blankets, and intravenous fluid was given with sympathomimetic support, potassium and antibiotics. After 24 hours she was conscious, the pulse had risen to 70 per minute, the blood pressure was 100/70 and there was good urinary output. The electrocardiogram had returned to normal, the J waves disappeared and the ST segment showed a normal aspect (Fig. 2). The patient then complained of abdominal pain and radiography showed mild ileus. Levels of amylase in the serum were 3000 units and, for urinary diastase, 16000 units. The cardiac enzymes were normal. Glucose, measured at 327 mg/dl of blood, returned to normal without treatment. Acute pancreatitis was diagnosed. The patient was discharged four days after admission in good clinical condition. Discussion A distinctive J deflection (or Osbom wave) is known to occur at the junction of the QRS complex and ST
segment in accidental hypothermia. This wave was present in 11 of 19 patients described by Duguid et al. [l]. In our patient, the wave was so marked that, in the emergency room, the diagnosis of acute myocardial infarction was considered. Two patients have recently been reported [2] who received thrombolysis for cardiovascular conditions mimicking acute myocardial infarction: namely, pericarditis and thoracic aortic dissection. Both patients required surgery and one died. Thrombolytic therapy in patients with evolving acute myocardial infarction improves survival. The impact of reperfusion is critically dependent on how early it is achieved. Keren et al. [3] advocate the use of thrombolytic therapy even in the patient’s home or in the ambulance on the way to the hospital. In patients dying from accidental hypothermia, however, hemorrhagic changes have been noted in the pancreatic tissues. The use of thrombolytic therapy, therefore, could produce serious complications in these patients. Accidental hypothermia must always be considered in the differential diagnosis of acute myocardial infarction before thrombolytic therapy is given. References 1 Duguid H, Simpson RG, Stowers JM. Accidental hypothermia. Lancet 1961;1214-1219. 2 Noto T, Hashimoto H, Sugai S, et al. Hypothermia caused
212
by antipsychotic drugs in a schizophrenic patient. J Clin Psychiat 1987;48:77. 3 Blankenship JC, Almquist AK. Cardiovascular complications of thrombolytic therapy in patients with a mistaken diagnosis of acute myocardial infarction. J Am Co11 Cardiol 1989;14:1579-1582.
4 Keren G, Weiss AT, Hasin Y, et al. Prevention of myocardial damage in acute myocardial ischemia by early treatment with intravenous streptokinase. N Engl J Med 1985;313: 1384-1389.