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Previous Volume 357:1873-1874 November 1, 2007 Number 18 Next

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To the Editor: During the past 10 years, there has been a precipitous rise in the number of reports of adverse drug reactions in Malaysia.¹ Of these reports, 20 have involved antiobesity medications, of which only phentermine and orlistat are legally available. Sibutramine, whose approval has been withheld owing to reports of adverse reactions, has been available through the black market.²

The use of the appetite suppressant phenylpropanolamine has been associated with myocardial infarction in patients with angiographically normal coronary arteries.³ To date, no similar data have been reported with regard to phentermine or sibutramine. We report on two otherwise healthy young women who had myocardial infarction with acute ST-segment elevation associated with the use of phentermine and sibutramine.

Patient 1 was a 35-year-old woman in whom acute ST-segment elevation (Figure 1A) and hypotension developed after the induction of general anesthesia for liposuction. Cardiac biomarkers were elevated (creatine kinase level, 445 U per liter; troponin T level, 1.86 µg per liter). Echocardiography revealed septal hypokinesia. The coronary arteries appeared normal on angiography.

View larger version (117K): [in this window] [in a new window]   Figure 1. Electrocardiographic Changes Indicating Acute Anteroseptal Myocardial Infarction in Patient 1 (Panel A) and Acute Inferior Myocardial Infarction in Patient 2 (Panel B).

 
The patient reported having had asthma since childhood, with mild, intermittent symptoms while she was using bronchodilators; she reported that she had not used these medications recently. She reported having no other medical illnesses and having received no other medications; she was a nonsmoker. She was overweight (body-mass index [the weight in kilograms divided by the square of the height in meters], 29), and she had undergone two previous liposuction procedures for her abdomen and buttocks. She reported having taken phentermine intermittently in the past and for 3 consecutive days before her admission for this procedure.

Patient 2 was an otherwise healthy 24-year-old woman who presented to the emergency room with severe, recurrent retrosternal chest pains. Electrocardiography showed acute inferior myocardial infarction (Figure 1B). Peak levels of serum creatine kinase and troponin T were 3450 U per liter and 4.25 µg per liter, respectively. The results of coronary angiography were normal. She had no other medical illnesses, was not taking any medications, and was a nonsmoker. She reported having taken sibutramine for the previous 3 months.

Investigations were pursued to rule out other diagnoses in Patient 1 and Patient 2, including cocaine abuse, viral myocarditis, aortic dissection, hypercoagulable states, and autoimmune vasculitis.⁴ In both patients, electrocardiography showed complete resolution of the ST-segment elevation within 24 hours. The absence of any attendant cardiovascular risk factors and the negative results of other studies led us to conclude that the use of appetite suppressants was responsible for the myocardial infarction in each of the two patients.

Shah M. Azarisman, M.M.E.D.
International Islamic University Malaysia
25200 Kuantan, Malaysia
risman1973{at}hotmail.com

Yahya A. Magdi, M.M.E.D.
Saidin Noorfaizan, M.R.C.P.
Maskon Oteh, M.R.C.P.
University Kebangsaan Malaysia
56000 Kuala Lumpur, Malaysia

References

1. Annual report of the Malaysian Adverse Drug Reactions Advisory Committee 2005. Kuala Lumpur, Malaysia: National Pharmaceutical Control Bureau, Ministry of Health, 2005. 
2. Dangers of slimming pills. The Professional Bulletin of the National Poison Centre, Malaysia (online). August 2002. (Accessed October 11, 2007, at http://www.prn2.usm.my/mainsite/bulletin/2002/prn35.html.)
3. Pilsczek FH, Karcic AA, Freeman I. Dexatrim (phenylpropanolamine) as a cause of myocardial infarction. Heart Lung 2003;32:100-104. [CrossRef][Web of Science][Medline]
4. Chandrasekaran B, Kurbaan AS. Myocardial infarction with angiographically normal coronary arteries. J R Soc Med 2002;95:398-400. [Free Full Text]

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This article has been cited by other articles:

• Ernest, D., Gershenzon, A., Corallo, C. E, Nagappan, R. (2008). Sibutramine-Associated QT Interval Prolongation and Cardiac Arrest. The Annals of Pharmacotherapy 42: 1514-1517 [Abstract] [Full Text]