Matija Kozak

Ventricular tachycardia induced by abuse of ephedrine in a young healthy woman

ZusammenfassungEINLEITUNG: Ephedrin, beziehungsweise pflanzliche Ephedra-haltige Produkte werden gelegentlich zur Verbesserung sportlicher Leistungen und zur unterstützung der Gewichtsabnahme verwendet. Die schwerwiegendsten Nebenwirkungen sind kardiovaskulärer Natur – nämlich akuter Myokardinfarkt, ausgeprägte Hypertonie, Myocarditis und schließlich letale kardiale Arrhtymien. FALLBERICHT: Eine 19-jährige Frau nahm Ephedrin zur Verbesserung ihrer sportlichen Leistung ein. Nach zehntägiger Einnahme entwickelte sie eine hämodynamisch wirksame ventrikuläre Tachykardie, welche weder auf Kardioversion noch auf Amiodaron ansprach. Nach 60 Stunden – wahrscheinlich nach ausreichendem Abfall ihrer Plasma-Ephedrin-Spiegel – konvertierte sie wieder in Sinusrhythmus. Elektrophysiologisch konnte ihre ventrikuläre Tachykardie ausgelöst und erfolgreich abliert werden. Innerhalb der einjährigen Kontrollzeit kam es zu keinem Rezidiv. DISKUSSION: Die Einnahme von Ephedrin kann nicht als der einzige Grund für die Rhythmusstörung unserer Patientin angesehen werden. Es ist allerdings sehr wahrscheinlich, dass Ephedrin die Attacke bei vorbestehender, zu Grunde liegender idiopathischer ventrikulärer Tachykardie ausgelöst hat. Obwohl die Patienten die erste Attacke der ventrikulären Tachykardie zu jedem Zeitpunkt ihres Lebens hätte haben können, erscheint ein nur zufälliges Auftreten nach dem Ephedrin-Abusus sehr unwahrscheinlich. SCHLUSSFOLGERUNG: Unserer Fallbericht zeigt, dass Ephedrin alleine – oder in Kombination mit Substanzen, die seine Wirkung auf das kardiovaskuläre System verstärken – paroxysmale ventrikuläre Tachykardien auf nicht ischämischer Basis auslösen kann. Da die Verwendung von Ephedrin das Risiko des Auftretens von lebensbedrohlichen Arrhythmien in sich birgt, sollte von seiner Einnahme dringend abgeraten werden.SummaryINTRODUCTION: Ephedrine or ephedra herbal products have occasionally been used to enhance sports performance and energy or to aid weight loss. The most serious side effects are those on cardiovascular function, including acute myocardial infarction, severe hypertension, myocarditis and lethal cardiac arrhythmias. CASE REPORT: A 19-year-old woman was taking ephedrine to enhance her sports performance. After 10 days of this medication she developed hemodynamically unstable ventricular tachycardia resistant to cardioversion and amiodarone treatment. She converted to sinus rhythm 60 hours later, presumably when the plasma ephedrine level had sufficiently decreased. In an electrophysiological study the ventricular tachycardia could be induced and successfully ablated. There were no recurrences during follow-up of more than a year. The use of ephedrine carries a risk of development of life-threatening arrhythmias. DISCUSSION: Ephedrine alone cannot be considered as the ultimate cause of tachycardia in our patient; however, it is highly probable that ephedrine triggered the tachycardic attack. The proarrhythmic effect most likely occurred because of underlying idiopathic left ventricular tachycardia. Although the patient could have developed her first attack of ventricular tachycardia at any time in her life, it is highly improbable that the attack following the ephedrine abuse was purely coincidental. CONCLUSION: Our experience with the reported patient shows that ephedrine alone, or in combination with substances that increase its effects on the cardiovascular system, may also trigger paroxysms of non-ischemic ventricular tachycardia. The use of ephedrine carries a risk of development of life-threatening arrhythmias and should be discouraged.

May-Thurner syndrome: old acquaintance, new perspective

SummaryMay-Thurner syndrome (MTS) results from a frequent anatomic variant in which compression of the left common iliac vein between the body of the fifth lumbar vertebra and the pulsating right common iliac artery can cause deep venous thrombosis (DVT) of the left lower limb. While anticoagulation remains the mainstay treatment of acute DVT, catheter-directed thrombolysis combined with stenting provides a safe and effective method for relieving acute symptoms and preventing postthrombotic syndrome in patients with MTS. In this article the diagnostic and treatment methods are presented in the case report of a 65-year-old woman with MTS who suffered iliofemoral DVT. Knowledge of anatomy is crucial for understanding and recognizing MTS as well as for treating MTS with endovascular procedures.

Association of Haemostasis Activation Markers with Thrombophilia and Venous Thromboembolism

Thrombophilia (TF) is defined as an inherited or acquired tendency to develop thrombosis. TF creates a state of hypercoagulability, i.e. haemostasis activation without actual clot formation which can be detected in vitro by specific laboratory techniques. Thrombosis as a clinical phenomenon, however, only occurs when the balance between pro-coagulant and anti-coagulant elements of haemostasis is disrupted to such an extent that it leads to clot formation in the circulating blood. TF is most commonly associated with an increased risk of thrombosis in the venous system, i.e. venous thromboembolism (VTE). VTE is a common disease with an annual incidence of about 1 case per 1000 person-years and is a cause of substantial morbidity and mortality worldwide (White, 2003). Furthermore, it is a chronic disease that often recurs. A third of patients with first VTE, experience a recurrence within the next 5 to 8 years. Recurrence is best prevented since it is fatal in 5 % of patients and late sequelae, such as post-thrombotic syndrome, are also very common (Schulman et al, 2006). The standard treatment for acute VTE (unfractionated or low-molecular-weight heparin, followed by vitamin K antagonists for at least several months) reduces the risk of recurrence by 80 to 90 % (Kearon et al, 2008). Although ideally all patients should receive long-term treatment with vitamin K antagonists to reduce the risk of recurrence, one has to bear in mind the 2 -3 % annual incidence of major bleeding on anticoagulant treatment (Ansell et al, 2008). The duration of anticoagulant treatment should therefore be tailored individually to optimize the preventive action of treatment with the minimum risk of bleeding. The likelihood of recurrence varies among individuals and is strongly influenced by the presence of clinical risk factors. Patients whose first VTE was triggered by a circumstantial risk factor (provoked VTE) have a lower risk of recurrence than patients whose event was unprovoked (idiopathic VTE), or who carry persistent risk factors (Kearon et al, 2008). It is, however, arguable whether the level of risk estimated from clinical risk factors alone justifies long-term anticoagulation. For a long time it was thought that screening for TF, a persistent risk factor for VTE, would facilitate clinical decision-making in determining the duration of anticoagulant treatment.

Priporočila za odkrivanje in zdravljenje periferne arterijske bolezni

In the article, recommendations for the diagnostics in suspected peripheral arterial disease are presented together with therapeutic procedures and long-term follow-up of the affected patients.

Recommendations for the diagnosis and treatment of chronic venous disease.

Clinical manifestations of chronic superficial venous insufficiency are described, followed by recommendations for diagnostic evaluation and various treatment possibilities.

Recidivne tromboze arterij spodnjega uda pri bolniku s trombocitopenijo, povzročeno s heparinom – Prikaz primera

Background: Heparin-induced thrombocytopenia (HIT) is an immune-mediated disorder following heparin therapy presenting with thrombocytopenia and associated arterial or/and venous thrombosis (heparin induced thrombocytopenia with thrombosis–HITT). Unrecognised HIT can lead to severe complications like limb amputation and death. Case report: We report a case of a patient who presented with HIT-associated recurrent lower limb arterial thrombotic occlusions and popliteal venous thrombosis 29 days after coronary bypass graft surgery. The patient underwent urgent thrombectomy of superficial femoral, popliteal and posterior tibial artery. Because of recurrent thrombotic occlusions of lower limb arteries three surgical revisions were performed. The platelet count decreased from 124 × 10/l to 53 × 10/l on the fifth day after the first intervention. After clinical suspicion of HIT, heparin was discontinued and fondaparinux was started. Arterial thrombosis did not recur and the patient recovered without consequences.