A 22-year-old African American male presented to the ER with acute onset of "pressure-like" substernal, nonradiating chest pain. His symptoms started while playing basketball. The pain was associated with shortness of breath and nausea. He had no significant past medical history or family history of coronary artery disease or sudden deaths. He denied excessive caffeine use, smoking, or alcohol intake. There was no reported use of any illicit drugs such as cocaine or amphetamines and was physically very active. Vital signs on admission included blood pressure of 138/89 mmHg, heart rate of 94/min, and respiratory rate of 22 breaths/min. His BMI was 28. Physical examination was unremarkable with no chest tenderness on palpation and no jugular venous distention. Heart sounds were normal with no murmurs or additional sounds. The electrocardiogram showed ST-segment elevation myocardial infarction (STEMI) in leads II, III, aVF, and V4-V6 (Figure 1). On subsequent EKGs, the patient had new ST-segment elevations in anterolateral leads with dynamic changes. Laboratory studies were pertinent for a troponin-I level of 0.83 ng/ml. The patient was given aspirin and ticagrelor loading doses, metoprolol succinate 25 mg, intravenous morphine, intravenous heparin drip, and sublingual nitroglycerin which did not relieve his chest pain.
The patient was taken for emergent cardiac angiography within 60 minutes of presentation and revealed acute dissection with thrombosis of the distal left main coronary artery (LCA) leading into the proximal left anterior descending artery (LAD) (Figures 2 and 3). An EBU 3.5 guide catheter was advanced over the wire with repeat injection of the left main performed revealing persistence of acute occlusion. Repeat angiography after balloon inflation revealed significant improvement in flow from TIMI 2 to TIMI 4. An extending thrombus was noted in the distal LAD which was suctioned out. Following this, a bare metal stent was inserted in the distal LCA ostial and the proximal LAD (Figures 4 and 5).
After catheterization, the patient was pain-free and hemodynamically stable. He was on epitifibatide infusion for a total of 18 hours. Other medications including carvedilol, lisinopril, aspirin, ticagrelor, and atorvastatin were initiated. The patient's peak troponin went up to 48.56 ng/ml in less than 24 hrs of initial laboratory studies and subsequently was trending down. Additional laboratory studies including hemoglobin A1c and lipid profile were normal. He was also worked up for thrombotic conditions which might lead to arterial thrombi such as homocystinemia and antiphospholipid antibody syndrome both of which were negative. Transthoracic echocardiography performed revealed preserved left ventricular systolic function normal with ejection fraction estimated to be 0.50 to 0.54%. There was no patent foramen ovale that might have led to paradoxical embolus. A urine and serum toxicology screen was also done on the patient who came back as negative for cocaine or methamphetamine.
After the procedure, the patient was further questioned to elicit any history that might shine light to the etiology of his STEMI. He admitted to the use of two different weight-loss products (Performix  stim-free; Performix SST) for the past 1 year, taking one capsule up to three times a day as indicated on the product label. However, he took Performix SST for the first time on the afternoon of presentation, drinking 3 scoops mixed with water, approximately 2 hours before started playing basketball. On reviewing, the contents of the supplement, it was noted to contain synephrine, an epinephrine analogue. Other contents of the mixture consisted of anhydrous caffeine, sensoril ashwagandha extract, bitter orange extract, n-methyltyramine, hordenine, tyramine, octopamine, huperzine A, yohimbine HCL, mucuna pruriens, and Bioperine. The patient was advised to avoid the use of the supplements. He was discharged home from the hospital with outpatient cardiology follow-up and advice to be maintained on dual antiplatelet therapy for at least one year.