Coronary vasospasm and sumatriptan.

Abstract

EDITOR,-John A Henry's editorial' and Ibrahim H Fahal and colleagues' drug point2 highlight a growing medical problem arising from the recreational misuse of ecstasy (3,4-methylenedioxymethamphetamine or MDMA). For each relatively rare and major complication of ecstasy, however, we suspect that many lesser events will go unrecorded. These will take their silent toll of the people concerned and consume valuable resources in medical institutions.Two young men were brought to the accident and emergency department at this hospital by ambulance. The first was aged 18 and had suffered a fit after taking ecstasy. He admitted to having had a fit one month earlier, also after misuse of ecstasy. Examination showed a sinus tachycardia but no other abnormality. He discharged himself from casualty. The second patient collapsed after complaining of a headache and was carried in on a stretcher. We suspected that he had had a fit, but no eye witnesses accompanied him. He was drowsy but scored 15 on the Glasgow coma scale. He had a tachycardia and both biochemical and electrocardiographic evidence of hyperkalaemia. He was given activated charcoal and admitted for overnight observation. On discharge the next morning he stated that his experience would not stop him using ecstasy again.We suspect that many acute hospitals throughout the country could relate similar stories. Although reports of chronic psychosis and acute rhabdomyolysis associated with misuse of ecstasy give cause for concern, we believe that the main burden for hospital and ambulance services will be the more mundane and often unreported effects of acute intoxication.

Migraine and Cluster Headache--Their Management with Sumatriptan: A Critical Review of the Current Clinical Experience

“…Since coronary vasoconstriction is predominantly mediated by 5HT 2 receptors (50,51,137), where sumatriptan (in contrast to ergot alkaloids) has no activity, coronary vasospasm is less likely. Although recent hypotheses suggest that occult endothelial dysfunction diminishes the basal release of nitric oxide in coronary arteries, and may enhance the vasoconstrictor effects of sumatriptan (147), in fact the constriction in atheromatous sections of artery after sumatriptan was even less than that in "normal" segments (148).…”

“…The adverse events of ergotamine are well documented and may be attributed to the activation of a wide variety of receptor types. Although recent hypotheses suggest that occult endothelial dysfunction diminishes the basal release of nitric oxide in coronary arteries, and may enhance the vasoconstrictor effects of sumatriptan (147), in fact the constriction in atheromatous sections of artery after sumatriptan was even less than that in "normal" segments (148). This non-selective action of ergotarnine has been demonstrated in animal studies where, unlike sumatriptan, it causes pressor effects, as seen in pithed rats, and spasmogenic activity in isolated uterine smooth muscle.…”

Vasospasm‐lnduced Myocardial Infarction With Sumatriptan

“…Postmarketing reports of coronary vasospasm have been documented. [9][10][11][12] Willet et al described a 47-year-old male patient with cluster headache who experienced chest pain and electrocardiogram changes after sumatriptan, but had prior episodes of chest pain unrelated to medication; he was also using concomitant vasoconstrictors, including methysergide and ergotamine. 9,10 Ottervanger et al described a 47-year-old female patient with cluster headache who developed an inferior myocardial infarction after using sumatriptan.…”

“…4,8 Electrocardiogram changes suggestive of transient ischemia have been reported. 3,[9][10][11][12] Isolated instances of angina, arrhythmia, myocardial infarction, and death have been reported after administration of sumatriptan. [13][14][15][16][17] It is often difficult to discern whether unsuspected coronary artery disease contributed to adverse cardiac outcomes with sumatriptan.…”