Friday, 22 September 2017

Multiple Thromboembolic Stroke and Myocardial Infarction in a Young Male in the Setting of Amphetamine Use


Amphetamines are first line treatment for Attention-Deficit Hyperactivity Disorder (ADHD). Known to have serious cardiovascular adverse effects such as MI, Stroke, and sudden death specially if used in high doses or long term. ADHD patients are predisposed to have concomitant substance use disorder. Substances like cocaine and marijuana increase risk of cardiovascular events. By knowing these, clinicians must be cautious in prescribing CNS stimulant agents. Precise personal, medical, drugs and medication history needs to be obtained before and during treatment. Herein, we present a young male with ADHD treated with amphetamines and concomitant marijuana use who presented with multiple thromboembolic stroke and acute myocardial infarction.

Many studies have revealed high-doses and long-term use of amphetamines associated with numerous adverse effects, especially serious cardiovascular events and sudden death. Multiple cases have reported atrial filtration and acute myocardial infarction in recreational amphetamine abusers. Other psychiatric illnesses such as mood disorders (38%), anxiety (47%) and poor impulse control (20%) are also found among adults with ADHD resulting in a higher likelihood of leading an unhealthy lifestyle (i.e obesity, smoking, substance abuse, etc) and subsequently cardiovascular events. Studies have revealed that 15% of ADHD patients have concomitant substance use disorders. Substances like cocaine and marijuana increase risk of cardiovascular events. World Health Organization (WHO) recently reported that chronic use of cocaine may be associated with myocardial infarction and stroke.

Gerhard et al study reported that 80% of adult patients with ADHD with evidence of ≥ 1 preexisting cardiovascular diseases were treated with CNS stimulants. Despite knowledge of preexisting cardiovascular disease (10.5%) in ADHD patients, no significant reduction in stimulants prescription has been observed.A 37-year-old man presented to the emergency department with left facial droop and left sided weakness which started 45 minutes prior to admission. All history was obtained from his wife because he was intubated upon arrival to emergency ward. He was diagnosed with ADHD at age 13 and was prescribed amphetamine-based medication up until he graduated from college. Amphetamine was re-started by his primary care physician one year ago due to the patient`s lack of concentration at his new job. He was taking Adderall XR 25 mg daily. According to his wife he was in his normal state of health until afternoon of admission day when he suddenly developed left facial droop and left sided weakness. He did not have reported chest pain, nausea or diaphoresis. 

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