Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
Journal of Biomedical Engineering and Technology
American Journal of Microbiological Research
Biomedical Science and Engineering

We are pleased to announce that submissions are now being accepted for peer review for all the journals across all our subject areas in SciEP.

Please submit your manuscript via our online submission system:
http://www.sciepub.com/author/signin

To unsubscribe from our mailing list, please click on the following link: unsubscribe

I am looking forward to hearing from you.

Kind regards,

David Rain
Email:join@sciepub.com
Science and Education Publishing (http://www.sciepub.com)

Yohimbine Induced Type II Myocardial Injury: An Underrecognized and Dangerous Adverse Effect

Jeffrey Song*, Tariq Sharman

Department of Medicine, Heritage College of Osteopathic Medicine at Ohio University, Southern Ohio Medical Center, Portsmouth, Ohio, U.S.A.

Abstract: Yohimbine is an Indoloquinolizidine alkaloid derived from the bark of the African tree Pausinystalia johimbe, as well as from the bark of the unrelated South American tree Aspidosperma quebracho-blanco. It is commonly sold as a dietary supplement for the purpose of enhancing libido, weight loss and natural bodybuilding aids. Yohimbine has high affinity for the α₂-adrenergic receptor, moderate affinity for the α₁ receptor, dopamine D₂ receptor, and weak affinity for the dopamine D₃ receptors and some of the serotonin receptors. Depending on dosage, Yohimbine can either increase or decrease systemic blood pressure (through vasoconstriction or vasodilation, respectively). We present a 51-year-old male who presented with substernal chest pressure and the sensation of a “pounding heart” after starting Yohimbine as a dietary supplement. He was found to have type II myocardial injury characterized by elevated troponin levels. We propose that the mechanism for this was 1) elevation of blood pressure and sinus tachycardia causing myocardial ischemia due to increased myocardial oxygen demand and supply mismatch, 2) cardiac norepinephrine release causing direct non-ischemic norepinephrine mediated myocardial injury and 3) increased sympathetic outflow mediated coronary vasoconstriction and spasm causing ischemia.

Keywords: Yohimbine, Hypertension, Norepinephrine, α₂ receptor, Type II NSTEMI, Tachycardia, Erectile Dysfunction

Received June 27, 2019; Revised August 06, 2019; Accepted August 14, 2019

Citation: Jeffrey Song, Tariq Sharman, Yohimbine Induced Type II Myocardial Injury: An Underrecognized and Dangerous Adverse Effect. American Journal of Medical Case Reports, 7 (11). 271-273. January 2019. doi:10.12691/ajmcr-7-11-2

1. Introduction

Yohimbine is an Indoloquinolizidine alkaloid derived from the bark of the African tree Pausinystalia johimbe, as well as from the bark of the unrelated South American tree Aspidosperma quebracho-blanco [1,2,3]. Yohimbine is an alpha-2 adrenergic antagonist. While Yohimbine behaves as an aphrodisiac in some mammals, it does not do so in humans [8]. In the United States, Yohimbine preparations are sold as dietary supplements for enhancing libido, weight loss and as aids for bodybuilding [8]. Because Yohimbine has the highest affinity for the α₂ receptors, small doses can increase blood pressure by causing a relatively selective α₂ blockade [4]. We are presenting a 51-year-old male who presented with substernal pressure and the sensation of a “pounding heart” after recently starting a new “energy pill” called Yohimbine and was found to have type II Non-ST Segment Elevation Myocardial Infarction (NSTEMI).

2. Case Report

A 51-year-old male with a past medical history of hypertension, hypercholesterolemia, obstructive sleep apnea and active smoker presented to the emergency department complaining of a “pounding heart” and substernal pressure of 1 day in duration. He reported that he recently started a new “energy pill” called Yohimbine. Home medications included Losartan, Amlodipine and Rosuvastatin. At presentation, his heart rate (HR) was 132 beats per minute (bpm) and his blood pressure (BP) was 173/108 millimeters of mercury (mmHg). Physical examination was unremarkable. Laboratory data revealed an initial Troponin-I of 0.03 nanogram per milliliter (ng/mL) which trended up to 0.10 ng/mL after six hours, and subsequently returned to 0.04 ng/mL twelve hours later. Thyroid stimulating hormone was within normal ranges. Electrocardiogram initially revealed sinus tachycardia at 108 bpm, which later normalized (Figure 1 and Figure 2). Echocardiography revealed a normal left ventricular ejection fraction (LVEF) of 60%, with no wall motion or valvular abnormalities. Stress Myocardial Perfusion Imaging revealed a small area of reversible, mildly decreased perfusion in the anteroseptal and apical segment of the left myocardium. Subsequently, a coronary angiogram demonstrated only a mild 30% distal stenosis involving the distal Left Anterior Descending coronary artery. The patient’s palpitations and chest discomfort subsided. HR & BP normalized in the hospital.

Figure 1. EKG showing sinus tachycardia at 108 bpm

Figure 2. EKG showing resolution of sinus tachycardia

3. Discussion

Yohimbine is an Indoloquinolizidine alkaloid derived from the bark of the African tree Pausinystalia johimbe and from the bark of the unrelated South American tree Aspidosperma quebracho-blanco [1,2,3]. Yohimbine has high affinity for the α₂-adrenergic receptor, moderate affinity for the α₁ receptor, dopamine D₂ receptor, and weak affinity for the dopamine D₃ receptors and some of the serotonin receptors [4,5,6]. Depending on dosage, Yohimbine can either increase or decrease systemic blood pressure (through vasoconstriction or vasodilation, respectively). Because Yohimbine has the highest affinity for the α₂ receptor, small doses can increase blood pressure by causing a relatively selective α₂ blockade. Higher doses of oral Yohimbine may create numerous side effects, such as rapid heart rate, overstimulation, anomalous blood pressure, cold sweats, and insomnia. Yohimbine has been studied as a potential treatment for erectile dysfunction but there is insufficient evidence to rate its effectiveness. In some studies, the efficacy of Yohimbine as monotherapy in patients suffering from erectile dysfunction population is likely to be modest [2,7,8]. Yohimbine blocks the pre- and post-synaptic α₂ receptors. Blockade of post-synaptic α₂ receptors causes only minor corpus cavernosum smooth muscle relaxation, due to the fact that the majority of adrenoceptors in the corpus cavernosum are of the α₁ type. Blockade of pre-synaptic α₂ receptors facilitate the release of several neurotransmitters in the central and peripheral nervous system, such as nitric oxide and norepinephrine. Nitric oxide released in the corpus cavernosum is the major vasodilator contributing to the erectile process [8,9]. In our patient, we propose that Yohimbine caused Type 2 myocardial injury in the form of troponin elevation by: 1) elevation of BP and sinus tachycardia causing myocardial ischemia due to increased myocardial oxygen demand and supply mismatch [10], 2) Yohimbine induced cardiac norepinephrine release, causing direct non-ischemic norepinephrine mediated myocardial injury, a phenomenon also implicated in myocardial injury in the setting of heart failure and cocaine toxicity [11,12], and 3) increased sympathetic outflow mediated coronary vasoconstriction and spasm causing ischemia [13].

4. Conclusion

There is need for public awareness of the sinister cardiovascular side effects of Yohimbine to the extent of causing myocardial injury, as it will continue to be a preferred alternative to prescription erectile dysfunction medications due to its quick onset of action when taken orally, its affordability and availability over the counter. We also urge clinicians to remember to inquire about Over-the-counter substances when taking a patient history.

References

[1]   | Sun J, Baker A, Chen P (September 2011). "Profiling the indole alkaloids in yohimbe bark with ultra-performance liquid chromatography coupled with ion mobility quadrupole time-of-flight mass spectrometry". Rapid Communications in Mass Spectrometry. 25 (18): 2591-602.
[2]   | Cohen PA, Wang YH, Maller G, DeSouza R, Khan IA (2015). "Pharmaceutical quantities of yohimbine found in dietary supplements in the USA". Drug Testing and Analysis. 8 (3-4): 357-69.
[3]   | EFSA Panel on Food Additives and Nutrient Sources Added to Food (ANS) (2013). "Scientific Opinion on the evaluation of the safety in use of Yohimbe (Pausinystalia yohimbe (K. Schum.) Pierre ex Beille". EFSA Journal. 11 (7): 1-46.

[4]  
Millan MJ, Newman-Tancredi A, Audinot V, Cussac D, Lejeune F, Nicolas JP, et al. (February 2000). "Agonist and antagonist actions of yohimbine as compared to fluparoxan at alpha(2)-adrenergic receptors (AR)s, serotonin (5-HT)(1A), 5-HT(1B), 5-HT(1D) and dopamine D(2) and D(3) receptors. Significance for the modulation of frontocortical monoaminergic transmission and depressive states". Synapse. 35 (2): 79-95.

[5]   | Arthur JM, Casañas SJ, Raymond JR (June 1993). "Partial agonist properties of rauwolscine and yohimbine for the inhibition of adenylyl cyclase by recombinant human 5-HT1A receptors". Biochemical Pharmacology. 45 (11): 2337-41.
[6]   | Baxter GS, Murphy OE, Blackburn TP (May 1994). "Further characterization of 5-hydroxytryptamine receptors (putative 5-HT2B) in rat stomach fundus longitudinal muscle". British Journal of Pharmacology. 112 (1): 323-31.
[7]   | Tam SW, Worcel M, Wyllie M (2001). "Yohimbine: a clinical review". Pharmacology and Therapeutics. 91 (3): 239
[8]   | Morales A (March 2000). "Yohimbine in erectile dysfunction: the facts". review. International Journal of Impotence Research. 12 (Suppl 1): S70-74.
[9]   | Andersson KE (September 2001). "Pharmacology of penile erection". Review. Pharmacological Reviews. 53 (3): 417-50.
[10]   | Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. Circulation. 2012; 126: 2020–35.
[11]   | Wang Y, Yu X, Wang F, et al. Yohimbine promotes cardiac NE release and prevents LPS-induced cardiac dysfunction via blockade of presynaptic α2A-adrenergic receptor. PloS one. 2013; 8(5): e63622.
[12]   | Januzzi JL, Jr, Filippatos G, Nieminen M, Gheorghiade M. Troponin elevation in patients with heart failure: On behalf of the third universal definition of myocardial infarction global task force: Heart failure section. Eur Heart J. 2012; 33(18): 2265-2271.
[13]   | Woodman OL, Vatner SF (1987). Coronary vasoconstriction mediated by α1- and α2-adrenoceptors in conscious dogs. Am. J. Physiol. 253 (2 Pt 2): H388-93.