Case of Acute inferior ST-elevation myocardial infarction due to delirium tremens: a report

Dr Maxwell D. Mirande at Western University of Health Sciences College of Osteopathic Medicine of the Pacific-Northwest, 200 Mullins Drive, Lebanon and colleagues have reported a rare case of Acute inferior ST-elevation myocardial infarction due to delirium tremens. The case has appeared in the Journal of Medical Case Reports.

Delirium tremens is a severe form of alcohol withdrawal syndrome. Literature documenting acute coronary events in the setting of alcohol withdrawal remains scarce. Delirium tremens (DT) is defined by delirium, hallucinations, seizures, autonomic hyperactivity, and psychomotor disturbances and they usually present within 48–96 hours. There have been very few cases documenting the link between alcohol withdrawal, ST-segment changes, and acute coronary events; however, the literature on this topic remains limited .

According to history 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. He reported having taken last alcoholic drink about 10 days ago; however, his 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 non occluded 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.

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Acute inferior ST-elevation myocardial infarction due to delirium tremens: a case report-