Letter to the Editor
Coronary vasospasm secondary to hypercholinergic crisis: An iatrogenic cause of acute myocardial infarction in myasthenia gravis

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Abstract

Patients with myasthenia gravis undergo lifelong treatment with anticholinesterase agents. While the heart is usually unaffected by this disease, clinicians should bear in mind the potential adverse interaction between cardiac function and the underlying myasthenic disease or its specific medications. In the present article we report, to the best of our knowledge for the first time in the literature, a case of vasospastic acute myocardial infarction due to iatrogenic hypercholinergic crisis secondary to anticholinesterase therapy in an elderly female with myasthenia gravis. This clinical vignette emphasizes the importance of taking into account the potential vasospastic effect of anticholinesterase drugs. Indeed, prompt recognition of the pathophysiology of myocardial ischemia due to iatrogenic hypercholinergic crisis is pivotal to the timely and appropriate management of this medical emergency, as well as prevention of future recurrences.

Introduction

Lifelong anticholinesterase treatment is common in patients with myasthenia gravis in order to control symptoms and to potentially improve life expectancy.[1] While usually safe, anticholinesterases can occasionally precipitate hypercholinergic crises and adversely affect the heart. We originally report a case of acute myocardial infarction due to iatrogenic hypercholinergic coronary vasospasm in an elderly female with myasthenia gravis.

Section snippets

Case

A 75-year-old woman was admitted to the Coronary Care Unit for acute myocardial infarction with antero-lateral ST-elevation (Fig. 1A). History was significant for past cigarette smoking. Myasthenia gravis was currently treated with a high-dose anticholinesterase agent (pyridostigmine) and corticosteroids, and oral anticoagulant therapy for recent pulmonary thromboembolism.

Because of the elevated INR before admission and the long pre-thrombolytic time (10 h), the patient was not treated with

Discussion

Patients with myasthenia gravis are treated lifelong with anticholinesterase agents, such as pyridostigmine, which are usually associated with few cardiovascular adverse effects at typical therapeutic doses [1], [3]. Indeed, medical emergencies associated with this disease (i.e. myasthenic crisis) are usually due to subtherapeutic anticholinesterase effect leading to muscle weakness and ultimately to respiratory failure [3]. Nonetheless, clinicians should bear in mind the risk for adverse

Acknowledgements

The authors have no competing interest or funding source to declare.

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