Cardiogenic shock complicating myocardial infarction in a doped athlete

Abstract

Abuse of doping agents may pose a higher risk for heart disease including acute myocardial infarction. We report the case of a 50-year-old body-builder Caucasian man with a long-standing abuse of nandrolone and erythropoietin that developed a ventricular septal defect following acute myocardial infarction. This mechanical complication led to cardiogenic shock ultimately treated with the implantation of a circulatory support by means of extracorporeal membrane oxygenation. The patient subsequently underwent orthotopic heart transplantation. The association of intense isometric exercise, abuse of erythropoietin and nandrolone is likely to have predisposed to coronary thrombus formation and acute myocardial infarction, as the patient presented no traditional cardiovascular risk factors.

• Doping
• acute myocardial infarction
• shock
• circulatory support
• heart transplantation

A 50-year-old body-builder Caucasian man was referred to our tertiary center to undergo rescue percutaneous coronary intervention after failed fibrinolysis for ST-elevation acute myocardial infarction (AMI). The patient had no previous notable medical history and no traditional coronary risk factors but admitted regular long-standing abuse of nandrolone and erythropoietin. Results of pre-fibrinolysis laboratory analysis showed hemoglobin level of 19.6 g/dl and hematocrit of 56%, platelets count was within normal range. Upon admission to our department the patient presented with persistent ST-elevation in lead V1-V4 and hemodynamic compromise. Coronary angiography performed five hours after symptoms onset revealed thrombosis of the proximal left anterior descending coronary artery. Angioplasty and stenting were performed (Figure 1) in the presence of an intra-aortic balloon pumping. About 30 min following the procedure the patient developed cardiogenic shock. He was obtunded, diaphroretic, tachycardic, tachypnoic and anuric; systolic blood pressure was 80 mmHg. A transthoracic echocardiogram showed a severe contractile dysfunction with ejection fraction 15% and the presence of a post-ischemic apical ventricular septal defect (Figure 2). He was intubated, treated with inotropes and placed on mechanical circulatory support by extracorporeal membrane oxygenation via the right femoral artery. The patient subsequently underwent orthotopic heart transplantation (HTX) and his postoperative course was uneventful. Gross and microscopic pathology of the explanted heart showed no evidence of atherosclerotic coronary artery disease (CAD). More specifically, histologic section of the stented arterial segment showed persistence of localized areas of platelet-rich thrombus underneath the strut along with presence of inflammatory cells. The patient was regularly discharged home after a short period of physical and cardiac rehabilitation and no medium-term complications were appreciated on the latest available follow-up assessment at six months following HTX.

Figure 1.  Coronary angiography demonstrating left anterior descending coronary artery thrombosis (A) successfully treated with angioplasty and stenting (B).

Figure 2.  Sub-costal view, on the transthoracic echocardiogram, showing apical ventricular septal defect (arrow in the zoom mode).

Abuse of illicit drugs, mainly cocaine, has risen to epidemic levels both in Europe and North America, and so has the number of associated cardiovascular complications [1], [2]. Doping is also being reported at a higher prevalence and it has reached the proportion of a social problem rather than just a sports-related issue as compared to the past [3]. Use of doping agents may also pose a serious risk for heart disease including AMI [3]. High doses of erythropoietin and nandrolone are associated with increased hematocrit, hypertension and thromboembolism [4], [5]. Occurrence of thrombus formation despite the presence of anatomically normal coronary arteries has been reported in several case studies of body-builders self-administering anabolic steroids, including nandrolone [6]. Proposed potential underlying mechanisms for an increased risk of arterial thrombosis due to anabolic steroids include increased levels of several pro-coagulant factors, decreased fibrinolytic activity, increased platelet aggregation, and decreased synthesis of prostacyclin [6]. Physical activity and acute exercise itself have also been both indicated as predisposing factors for thrombotic events occurring spontaneously or secondary to vasospasm [7], [8]. In the reported case the association of intense isometric exercise with abuse of erythropoietin and nandrolone is likely to have mediated the development of a pro-coagulant state ultimately leading to acute coronary thrombosis and myocardial infarction, with the development of a life-threatening complication. Indeed the patient presented no traditional cardiovascular risk factors for CAD and no evidence of coronary artery atherosclerosis was found at anatomopathological study. His young age along with the absence of other co-morbidities and concomitant medical conditions, the intensive pharmacological and mechanical support and the prompt availability of a donor led to the favorable outcome of this patient.

Acknowledgements

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.