Mirande Maxwell D, Kubac George, Nguyen Anh T
Western University of Health Sciences College of Osteopathic Medicine of the Pacific-Northwest, 200 Mullins Drive, Lebanon, OR, 97355, USA.
Sky Lakes Medical Center, 2865 Daggett Avenue, Klamath Falls, 97601, OR, USA.
J Med Case Rep. 2019 Oct 9;13(1):306. doi: 10.1186/s13256-019-2246-x.
Delirium tremens is a severe form of alcohol withdrawal syndrome. Literature documenting acute coronary events in the setting of alcohol withdrawal remains scarce. An accepted hypothesis for the underlying process is focused on the hyperadrenergic state that leads to coronary vasospasm and increased myocardial oxygen demand.
A 47-year-old Caucasian man with a past medical history of tobacco and alcohol abuse, hypertension, and anxiety presented to the emergency department for crampy epigastric abdominal pain with intractable nausea and vomiting for the past 2 days. His reported last alcoholic intake was about 10 days prior; however, outpatient records indicated otherwise. He was admitted for electrolyte replacement and fluid resuscitation secondary to gastrointestinal losses from presumed early alcohol withdrawal syndrome. The following night, he developed acute substernal chest pain with elevated cardiac enzymes. Electrocardiography showed an acute inferoposterior infarct with reciprocal changes in leads V1-V4. The patient was taken for emergent catheterization, and a drug-eluting stent was placed in the middle of the left anterior descending artery. Postcatheterization electrocardiography showed sustained inferolateral ST elevations consistent with acute injury pattern. The patient had not required any benzodiazepines until this point. On the morning of catheterization, the patient's Clinical Institute Withdrawal Assessment for Alcohol-Revised score was 19 with a high of 25, and he was actively hallucinating. He was treated for delirium tremens and an acute coronary event along with an incidental pneumonia. He did not require any benzodiazepines during the last 4 days of admission, and he made a full recovery.
The prevalence of alcohol dependence in hospitalized patients is substantial. Although our patient was being treated with the standard protocols for alcohol withdrawal, he rapidly developed delirium tremens, which led to an acute inferior ST-elevation myocardial infarction in the setting of nonoccluded coronary vessels. This case report adds to the sparse literature documenting acute coronary events in the setting of alcohol withdrawal and suggests that our patient's ST-elevation myocardial infarction is not fully explained by the current coronary vasospasm hypothesis, but rather was in part the result of direct catecholamine-associated myocardial injury. Further research should be conducted on prophylactic agents such as β-blockers and calcium channel blockers.
震颤谵妄是酒精戒断综合征的一种严重形式。记录酒精戒断时急性冠状动脉事件的文献仍然很少。对于潜在过程的一个公认假说是关注导致冠状动脉痉挛和心肌需氧量增加的高肾上腺素能状态。
一名47岁的白人男性，有吸烟、酗酒、高血压和焦虑症病史，因过去两天出现痉挛性上腹部疼痛伴顽固性恶心和呕吐而到急诊科就诊。他报告的最后一次饮酒时间约为10天前；然而，门诊记录显示并非如此。他因推测为早期酒精戒断综合征导致的胃肠道丢失而入院接受电解质补充和液体复苏。第二天晚上，他出现急性胸骨后胸痛，心肌酶升高。心电图显示急性下后壁梗死，V1-V4导联有对应性改变。患者接受了紧急导管插入术，并在左前降支动脉中段置入了药物洗脱支架。导管插入术后心电图显示持续的下外侧ST段抬高，符合急性损伤模式。在此之前，患者一直未需要任何苯二氮䓬类药物。在导管插入术当天上午，患者的酒精戒断临床研究所修订评估量表评分为19分，最高分为25分，且他正在出现幻觉。他接受了震颤谵妄、急性冠状动脉事件以及附带肺炎的治疗。在住院的最后4天里，他未需要任何苯二氮䓬类药物，并完全康复。
住院患者中酒精依赖的患病率很高。尽管我们的患者正在按照酒精戒断的标准方案进行治疗，但他迅速出现了震颤谵妄，这导致在冠状动脉未闭塞的情况下发生急性下壁ST段抬高型心肌梗死。本病例报告补充了记录酒精戒断时急性冠状动脉事件的稀少文献，并表明我们患者的ST段抬高型心肌梗死不能完全用当前的冠状动脉痉挛假说解释，而是部分是直接儿茶酚胺相关心肌损伤的结果。应进一步研究β受体阻滞剂和钙通道阻滞剂等预防性药物。
