Letter to the Editor
Dilated cardiomyopathy secondary to methamphetamine intoxication (Shabu)
Miocardiopatía dilatada secundaria a intoxicación por metanfetaminas (shabú)
María Carrera-Morodoa,
, Adrián Fernández Sánchezb, José Cristóbal Díaz Villanuevac
Corresponding author
a Servicio de Urgencias, Hospital Universitario Sagrat Cor, CAP La Marina, ICS Barcelona, Barcelona, Spain
b Servicio de Urgencias, Hospital Universitario Sagrat Cor, CAP Guinardó, ICS Barcelona, Barcelona, Spain
c Servicio de Cardiología, Hospital Universitario Sagrat Cor, Barcelona, Barcelona, Spain
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There are mainly 3 dosage forms: <span class="elsevierStyleItalic">ice</span>, <span class="elsevierStyleItalic">speed</span> and base, which differ in the degree of purity. <span class="elsevierStyleItalic">Ice</span> or crystal, also known as shabu in the Philippines, has a purity of 80%, while <span class="elsevierStyleItalic">speed</span> has a purity of 10–20%. Recent years have seen a considerable increase in consumption in Spain.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> MA abuse has been linked to various cardiovascular manifestations.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 30-year-old woman from the Philippines, a chronic user of shabu for 10 years, who came to the hospital emergency department with a weeks-long history of dyspnoea. The patient reported progressive dyspnoea from moderate to minimal exertion, paroxysmal nocturnal dyspnoea, asthenia, and weight gain of up to 20 kg in the last 15 days. On arrival she was conscious and nervous, tachypnoeic and tachycardic, with use of the accessory muscles and subcostal retraction, with decubitus intolerance. Oxygen saturation was 89% room air, blood pressure 140/90 mm Hg. Physical examination revealed signs of anasarca, with significant oedema of the abdominal wall and limbs, as well as signs of pulmonary congestion. Suspecting acute heart failure, diuretic therapy was started with nitro-glycerine, oxygen therapy and morphine, with good tolerance and subsequent clinical course. Diffuse alveolar infiltrates were observed in both lung fields on chest X-ray. An echocardiogram showed findings consistent with dilated cardiomyopathy: moderate biventricular dilatation, overall hypocontractility with a left ventricular ejection fraction (LVEF) of 20%, and severe mitral regurgitation. Laboratory tests showed elevated troponins and pro B-type natriuretic peptide. During her stay on the hospital ward, she showed a favourable clinical course, with improvement of the congestive signs. Beta-blockers and angiotensin-converting enzyme inhibitors were started, and she was discharged for outpatient follow-up, recommending detoxification therapy. The patient stopped taking MA after discharge. Echocardiography was repeated at subsequent outpatient visits, showing an improvement in LVEF (50%).</p><p id="par0015" class="elsevierStylePara elsevierViewall">MA abuse produces different types of cardiovascular toxicities. The AMs generate arterial vasoconstriction due to their sympathomimetic effects and, consequently, hypertension or aortic dissection.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Coronary vasoconstriction can in turn generate ischaemia, electrocardiographic abnormalities such as long QT and secondary malignant arrhythmias,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> or even dilated cardiomyopathy (DCM) due to direct toxic effect, the latter being a cardiac manifestation well related to MA abuse. Nonischaemic DCM associated with MA consumption was first described in the 1980s in the United States. Two types of DCM have been defined based on progression: Persistent DCM (pDCM) when despite cessation of use and continued treatment there is no clinical or echocardiographic improvement and reversible DCM, when use has ceased, and chronic treatment has been maintained with good adherence and ventricular function recovery. Due to the rise in MA use in recent years, there has been an increase in the number of individuals requiring hospital care and the healthcare costs resulting from their complications.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> pDCM is associated with a worse course and a higher incidence of acute myocardial infarction. Under correct therapeutic adherence, clinical improvement is observed in approximately one year. Cessation of consumption and normal cardiac anatomy are the best studied predictors associated with such improvement, including disease reversal.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">We believe that AM-induced DCM should be suspected from the outset in recreational drug-using patients with symptoms suggestive of heart failure. The differential diagnosis of cardiac diseases is a priority for emergency physicians in order to avoid under-diagnosis of this entity, and thus improve the course and treatment from the first contact in the emergency department. Detoxification is considered the gold standard treatment in these cases, given the possible reversibility of DCM and the consequent decrease in morbidity and mortality. Multidisciplinary coordination and the involvement of the emergency and primary care physician is vital, providing advice and positive reinforcement to patients.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that they have not received any funding for this study.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "World drug report 2016" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "United Nations, Office on Drugs and Crime" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2016" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Methamphetamine and cardiovascular pathology: a review of the evidence" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. Kaye" 1 => "R. McKetin" 2 => "J. Duflou" 3 => "S. Darke" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1360-0443.2007.01874.x" "Revista" => array:6 [ "tituloSerie" => "Addiction" "fecha" => "2007" "volumen" => "102" "paginaInicial" => "1204" "paginaFinal" => "1211" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17565561" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The cardiac complications of methamphetamines" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "E.D. Paratz" 1 => "N.J. Cunningham" 2 => "A.I. MacIsaac" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.hlc.2015.10.019" "Revista" => array:6 [ "tituloSerie" => "Heart Lung Circ" "fecha" => "2016" "volumen" => "25" "paginaInicial" => "325" "paginaFinal" => "332" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26706652" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comparison of clinical characteristics and outcomes of patients with reversible versus persistent methamphetamine-associated cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S.X. Zhao" 1 => "S. Seng" 2 => "A. Deluna" 3 => "E.C. Yu" 4 => "M.H. Crawford" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.amjcard.2019.09.030" "Revista" => array:6 [ "tituloSerie" => "Am J Cardiol" "fecha" => "2020" "volumen" => "125" "paginaInicial" => "127" "paginaFinal" => "134" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31699360" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Methamphetamine-associated cardiomyopathy: patterns and predictors of recovery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Voskoboinik" 1 => "J.F. Ihle" 2 => "J.E. Bloom" 3 => "D.M. 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