Cardiomyopathy Associated With Ephedra‐Containing Nutritional Supplements

Dietary supplements containing ephedra alkaloids (also known as ma huang) were previously used in the United States for weight loss and athletic performance enhancement. Ephedrine is a potent sympathomimetic agent with direct and indirect effects on adrenergic receptors. Ephedrine and related alkaloids have been associated with adverse cardiovascular events, including acute myocardial infarction,1-4 severe hypertension, hypersensitivity myocarditis,5 fatal arrhythmias, and cardiomyopathy.6 We report a case of ephedra-associated cardiomyopathy with follow-up that shows improved cardiac function with cessation of the offending agent and with medical therapy. Our patient is a 36-year-old previously healthy white man who presented with a 2-month history of dyspnea on exertion, 3-pillow orthopnea, decreasing exercise tolerance, and progressive fatigue. He had taken a dietary supplement containing ephedra combined with other vitamins for the last 4 years. Other pertinent history included possible exposure to ticks. No history of viral illness, alcohol or recreational drug intake, or travel was elicited. There was no family history of cardiomyopathy. On physical examination, the patient was in no acute distress; vital signs demonstrated a blood pressure level of 108/76 mm Hg; heart rate, 120 beats per minute; and respiration rate, 20 breaths per minute. The patient was afebrile. There was mild jugular venous distension; the heart rate was regular and rapid with both S3 and S4 gallops. The lungs were clear, and extremities were without edema. The remainder of the results of the physical examination were normal. Laboratory findings included normal complete blood cell count, serum chemistry, and liver function test results. Serum ferritin and thyroid function test findings were normal. Immunologic testing for Toxoplasma species, Lyme disease, and Ehrlichia species were negative. Chest radiography showed cardiomegaly, and electrocardiography revealed sinus tachycardia. Two-dimensional echocardiography demonstrated left ventricular dysfunction with severe global hypokinesia and an estimated left ventricular ejection fraction (LVEF) of 10% to 15%. Right heart catheterization revealed a pulmonary capillary wedge pressure of 24 mm Hg and mild pulmonary hypertension. Left heart catheterization revealed an LVEF of 10% with severe global hypokinesia, a left ventricular end-diastolic pressure of 7 mm Hg, and a left dominant coronary system with normal coronary arteries. Right ventricular biopsy revealed minimal changes and probable idiopathic cardiomyopathy. The patient was advised to stop taking the ephedra-containing dietary supplement, and medical treatment was started with aspirin, a β-blocker, and an angiotensin-converting enzyme inhibitor, with subsequent symptom improvement. The patient could not tolerate spironolactone therapy because of hyperkalemia. Repeat echocardiography performed 3 years later showed marked improvement in left ventricular systolic function, with an estimated LVEF of 45% to 50%. Our case adds to the series of already published cases that show a temporal relation between ephedra alkaloids and their cardiac adverse effects.6-8 Ephedra alkaloids represented only 0.82% of the dietary supplements sold in the past; however, they accounted for 64% of the reported adverse events.9 Although the US Food and Drug Administration banned the marketing of any ephedra-containing dietary supplement in April 2004, the hazard remains from these supplements. The Food and Drug Administration ban is limited only to dietary supplements containing ephedra and does not cover products marketed as herbal remedies. In addition, there is a continuous threat posed by the availability of other agents that have pharmacodynamics similar to ephedra10 and by unregulated internet marketing of these as well as other banned agents.11, 12 We suggest that patients who present with new-onset cardiac failure should be questioned closely about the use of nonproprietary medications and nutritional supplements. Patients taking ephedra or any similar supplements should be advised to discontinue use immediately. Public awareness of the potential hazards of unregulated supplements is vital. In addition, regulatory authorities need to scrutinize supplements to eliminate the risk associated with these agents available in the marketplace.