34 year old male with chest pain and shortness of breath • Xray of the Week
Figure 1. 34 year old male with chest pain and shortness of breath.
Figure 2. A and B: Axial and coronal CT with cardiomegaly due to markedly dilated heart. Right pleural effusion (blue arrow). Low EF with contrast only in RA (red arrows) and RV (orange arrow). Reflux of contrast into the IVC (green arrow) and hepatic veins (white arrow) indicates tricuspid valve regurgitation.
C: Echocardiogram apical 4 chamber view. Mitral regurgitation as evidenced by a regurgitant jet extending into the RA (yellow arrow).
Methamphetamine (MA) and related compounds are the most widely abused drugs in the world after cannabis. It is a psychostimulant that causes an increase in the synapse of monoamine neurotransmitters, including dopamine, norepinephrine, and serotonin . Methamphetamines can be smoked, snorted, injected, or ingested orally. Methamphetamine is more potent, and its effects last longer than cocaine. Methamphetamine associated cardiomyopathy (MACM) is more common in younger age groups compared to patients with cardiomyopathy attributable to other causes. The development of MACM has been shown to be dose-dependent and amplified by repetitive use, binge pattern use, and concomitant use of other substances. Autopsy studies have shown MACM to be associated with extensive myocardial fibrosis, cellular vacuolization, and myocyte destruction [2, 3]. Cardiac complications of MA use include chest pain, hypertension, arrhythmia, aortic dissection, coronary vasospasm, cardiomyopathy, sudden cardiac death, and pulmonary arterial hypertension .
Figure 3. A. Axial and B. Coronal CT Scan. Same patient with RV thrombus (red arrows).
Typical findings reported on echocardiography are severe multi-chamber dilatation, reduced EF, mitral regurgitation (MR) Patients with MACM are also prone to developing intracardiac thrombi, with up to 33% for LV thrombus and 3.3% for RV thrombus [4, 5] (Fig. 3). Thrombus is likely due both to severe cardiac dysfunction and the prothrombotic state seen in MACM . And tricuspid regurgitation (TR), and pericardial effusion [6-9]. In general, patients with MACM have significantly larger LA, LV, and RV size, lower LVEF, and a higher rate of mitral regurgitation (MR) compared to other causes of dilated cardiomyopathy . In this case, there is severe tricuspid regurgitation (TR) with reflux of contrast into the inferior vena cava (IVC) and hepatic veins; pleural effusion is indicative of heart failure (Figs. 2 A, B). There is also MR visualized on the echocardiogram with a large regurgitant jet extending into the LA during systole (Fig. 2C). Aside from cessation of MA use, treatment of MACM is aimed at the specific pathology such as anticoagulation for intracardiac thrombus and diuresis/venodilators for volume overload.
1. Barr, A.M., et al., The need for speed: an update on methamphetamine addiction. J Psychiatry Neurosci, 2006. 31(5): p. 301-13. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1557685/
2. Reddy, P.K.V., et al., Clinical Characteristics and Management of Methamphetamine-Associated Cardiomyopathy: State-of-the-Art Review. J Am Heart Assoc, 2020. 9(11): p. e016704 DOI: 10.1161/jaha.120.016704. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428977/
3. Karch, S.B., The unique histology of methamphetamine cardiomyopathy: a case report. Forensic Sci Int, 2011. 212(1-3): p. e1-4 DOI: 10.1016/j.forsciint.2011.04.028. Retrieved from https://pubmed.ncbi.nlm.nih.gov/21664081/
4. Janardhanan, R. and A. Kannan, Methamphetamine Cardiotoxicity: Unique Presentation with Multiple Bi-Ventricular Thrombi. The American Journal of Medicine, 2016. 129(1): p. e3-e4 DOI: 10.1016/j.amjmed.2015.08.006. Retrieved from https://www.amjmed.com/article/S0002-9343(15)00780-9/fulltext
5. Schürer, S., et al., Clinical Characteristics, Histopathological Features, and Clinical Outcome of Methamphetamine-Associated Cardiomyopathy. JACC Heart Fail, 2017. 5(6): p. 435-445 DOI: 10.1016/j.jchf.2017.02.017. Retrieved from https://pubmed.ncbi.nlm.nih.gov/28571597/
6. Ito, H., et al., A comparison of echocardiographic findings in young adults with cardiomyopathy: with and without a history of methamphetamine abuse. Clin Cardiol, 2009. 32(6): p. E18-22 DOI: 10.1002/clc.20367. Retrieved from https://pubmed.ncbi.nlm.nih.gov/19330818/
7. Neeki, M.M., et al., Frequency of Methamphetamine Use as a Major Contributor Toward the Severity of Cardiomyopathy in Adults ≤50 Years. The American Journal of Cardiology, 2016. 118(4): p. 585-589 DOI: https://doi.org/10.1016/j.amjcard.2016.05.057. Retrieved from http://www.sciencedirect.com/science/article/pii/S0002914916309602
8. Wijetunga, M., et al., Crystal methamphetamine-associated cardiomyopathy: tip of the iceberg? J Toxicol Clin Toxicol, 2003. 41(7): p. 981-6 DOI: 10.1081/clt-120026521. Retrieved from https://pubmed.ncbi.nlm.nih.gov/14705845/
9. Yeo, K.K., et al., The association of methamphetamine use and cardiomyopathy in young patients. Am J Med, 2007. 120(2): p. 165-71 DOI: 10.1016/j.amjmed.2006.01.024. Retrieved from https://pubmed.ncbi.nlm.nih.gov/17275458/
Shama Jaswal is an International Medical Graduate, currently doing research at Mallinckrodt Institute of Radiology (MIR), Saint Louis. She aims at pursuing Diagnostic Radiology residency and poses a keen interest in research alongside academics. At MIR, she has been fortunate to work on various oncology projects including the project in which they studied how the difference in fat metabolism in both sexes can affect the cancer survival and outcome, and how this study can further improve prognosis through treatment modification. Shama is both an accomplished sprinter and singer having won several national competitions in in each discipline in India. She also has a strong passion for cooking and gardening.
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Kevin M. Rice, MD is the president of Global Radiology CME
Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.
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