tobacco is consumed in two forms : the smoked tobacco products , like cigarettes and shisha ( water pipe ) and the smokeless tobacco ( st ) .
also known as moist snuff or spit tobacco , is held in the mouth between the cheeks and gums instead of being smoked .
the dip rests on the inside lining of the mouth usually for a period depending on the user 's preference , between few minutes to an hour .
the st is primarily used in central asia , iran , afghanistan , pakistan , tajikistan , india , and in europe , like sweden .
the prevalence of st use in india is 20% , and significantly higher in males . in the united states ,
5.2% of young adults , between the ages of 18 and 25 , and 3.2% adults over the age of 26 , used st in 2006 . in sweden , around 20% of the adults used st .
there are no precise figures available on the exact prevalence of st usage in the gulf region , but most observers agree that is widely used by workers coming from asia , and it has been recently noticed that these products have gained popularity among adult and adolescent citizens .
proliferation of restrictions on the smoking area is the main reason behind many people using st , especially for the young , below 18 years of age .
other reasons are that it is presumed to be a less harmful alternative for those having difficulty quitting smoking and its easy affordability .
we report the case of a young man who presented with acute myocardial infarction . a thorough review of the risk factors
a previously healthy 21-year - old man presented with central chest pain that awakened him from sleep two hours before , associated with nausea , vomiting , dizziness , and shortness of breath .
he had used dipping st in the form of niswar ( sweka ) five to ten times per day [ figure 1 ] continuously for one year , which was preceded by the habitual use of both types of smoking for another year .
there was no past history of cardiac disease , diabetes , hypertension , hyperlipidemia , drug abuse or family history of coronary artery disease .
dipping smokeless tobacco in the form of niswar ( sweka ) on physical examination the heart rate was 100 beats / minute , regular , and the blood pressure was 100/70 mmhg .
a 12-lead electrocardiogram ( ecg ) showed st elevation in leads v2-v5 , i , avl with reciprocal st - segment depression in leads ii , iii , and avf [ figure 2a ] .
in the first few minutes of presentation , the patient developed cardiac arrest due to ventricular tachycardia ( vt ) , which rapidly disintegrated to ventricular fibrillation .
 v5 , i , and avl , with reciprocal st - segment depression in leads ii , iii , and avf .
( b ) patient 's electrocardiogram after successful fibrinolyitic therapy fibrinolyitic therapy was given at presentation as well as intravenous nitrate and heparin .
the chest pain subsided and st elevation was markedly reduced after 30 minutes [ figure 2b ] . apart from short runs of nun - sustained vt , he remained asymptomatic until the third hospital day , when the chest pain reappeared and a coronary angiogram was performed which revealed a 70% proximal left anterior descending artery ( lad ) lesion , 40% left circumflex artery ( lcx ) lesion , and a normal right coronary artery [ figure 3a ] .
even though the patient was on continuous intravenous nitrate , further intra - coronary nitrate failed to relieve a presumed coronary spasm .
angioplasty was performed and followed by a bare metal stent implantation for the culprit lesion in the lad [ figures 3b and c ] .
the laboratory tests showed a peak in the troponin - t level , of 5.056 ng / ml ( normal < 0.1 ng / ml ) , and creatine kinase mb of 350.6 u / l ( normal < 24 u /
the drug screen for cocaine , amphetamine , ethanol , barbiturates , benzodiazepines , methadone , opiates , phencyclidine , propoxyphene , and tetrahydrocannabinol was negative .
the thrombophilia screen for factor v leiden mutation , antiphospholipid antibodies , proteins c and s , and antithrombin levels was negative .
transthoracic echocardiography during admission revealed left ventricular segmental wall motion abnormalities and an ejection fraction of 28% .
( a ) coronary angiogram reveals a 70% proximal left anterior descending artery ( lad ) lesion and lcx : left circumflex artery ; ( b ) angioplasty shows the waist ; ( c ) lad after stent implantation .
many studies have shown contradictory results with regard to the cardiovascular effects of st . some have reported an association between st and cardiovascular complications.[57 ] some studies showed lower risk in comparison to those who smoked tobacco , while some studies failed to find such an association.[1012 ] bolinder et al . , reported an increased prevalence of circulatory disorders as well as cardiovascular mortality among snuz users in 1994 , but in this study the tobacco - specific nitrosamine content of the swedish snus was substantially reduced through changes in the manufacturing process . while , more recently hergens et al . , found no increased risk of mi from swedish snus ( rr 0.99 ; 95% ci 0.90  1.10 ) , the risk of fatal mi was higher among heavy users (  50 g per day ) ( rr 1.96 ; 95% ci1.08  3.58 ) . the cardiovascular short - term effect of st use have been documented .
the effects produced by nicotine were an increase in blood pressure and heart rate , plus an increase in cardiac stroke volume and coronary blood flow , as well as vasoconstriction .
nicotine is the main component of tobacco and is found to reach a higher concentration in st users in comparison to smokers .
furthermore , the endothelial dysfunction , which is a risk factor for mi , was found to be caused by st use .
hergens , hypothesized that the direct cardiovascular effect of nicotine could be the cause behind the severity of mi , and oral moist snuff contained substances such as fatty acids and flavonoids that could have a protective effect for mi , while , carbon monoxide , oxidant gases , and polycyclic aromatic hydrocarbons were substances present in cigarettes .
these substances and not nicotine could be the cause of an increase in the risk of mi among smokers . although it has not been reported before with st use , coronary artery spasm caused by smoking is well - recognized specially in young patients .
a presentation we thought the patient had coronary spasm and he was kept on nitrate infusion .
the failure to respond to intracoronary nitrate during angiography and the clear balloon waist during dilatation of the lad lesion raised the possibility of atherosclerotic plaque rupture behind the mi .
coronary spasm due to illicit drug abuse was excluded angiographically , as well as by negative history and an unrevealing drug screen .
the absence of clear risk factors for cad in this patient , except for st use , draw attention to the likelihood of rapid acceleration and / or enhanced vulnerability of atherosclerosis attributable to st use . due to the lack of information about the constituents of different types of st in different countries , the previous impression that st is less harmful should be handled carefully and abandoned until further studies are conducted .
its alternative use to quit smoking needs to be handled carefully . a prompt call for restriction and prohibition is advised .
 dipping smokeless tobacco ( st ) is used worldwide . 
 we report a case of acute myocardial infarction in a young patient , who consumed smokeless tobacco ( sweka ) for over one year . 
 st may be as harmful as smoking and carries adverse cardiac complications . 
 a prompt call for restriction and prohibition is advised and its alternative use to quit smoking must be abandoned . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION