J Cardiovasc Disease Res., 2016; 7(3): 130-132 A Multifaceted Peer Reviewed Journal in the field of Cardiology www.jcdronline.org | www.journalonweb.com/jcdr 130 Journal of Cardiovascular Disease Research, Vol 7, Issue 3, July-Sep, 2016 Case Report INTRODUCTION It is a well known fact that premenopausal women show a low incidence of ischemic heart disease. 1 It has been suggested that estrogens have car- dioprotective effects. Leuprolide, a gonadotropin-releasing hormone, acts as a potent inhibitor of gonadotropin secretion when therapeutic doses are given continuously. It results in decreased levels of luteiniz- ing hormone (LH) as well as follicle-stimulating hormone (FSH), and subsequently suppresses gonadal sex steroid production. erefore, it is used to treat uterine myoma, endometriosis, prostate cancer, and breast cancer. In premenopausal women treated with leuprolide, estrogens are reduced to postmenopausal levels. It is known that leuprolide is associ- ated with angina in men, but very few cases of ischemic heart disease have been reported in women undergoing treatment with leuprolide. 2 In this report, we describe a premenopausal woman on leuprolide therapy who presented with ST segment elevation (STE) myocardial infarction. CASE REPORT A 36-year-old premenopausal woman, on treatment with leuprolide for uterine myoma, was admitted to our hospital with continuous chest pain radiating to leſt upper limb since ten hours. She initially consulted her family doctor with anterior chest pain. A 12-lead electrocardiogram (ECG) showed ST elevation in leads V 2 through V 6 with q RBBB pattern (Figure 1). She was referred to our hospital for further management aſter receiving a loading dose of aspirin 325 mg, clopidogrel 300 mg and ator- vastatin 80 mg. She was on therapy with leuprolide, once every month planned for 3 months at a dose of 3.75 mg subcutaneously. Patient had received the second dose six days prior to this episode. She had prior his- tory of hypertension diagnosed six months back which was controlled on salt restricted diet and lifestyle modification. ere was no history of any cardiovascular symptoms and her blood pressures were normal dur- ing the leuprolide therapy as was reported from her gynecological case notes. She was a non-smoker and had no prior history of cardiovascular disease or collagen diseases. She had never taken a contraceptive drug. ere was no family history of ischemic heart disease. However, both her parents were hypertensive and well controlled on antihypertensives. At the time of admission, no physical abnormality was observed. How- ever blood chemistry revealed a slight increase in the level of creatinine- phosphokinase and positive serum troponin-T. Transthoracic echocar- diography revealed mild hypokinesis of the anterior apical portion of the leſt ventricle. Patient was offered percutaneus coronary intervention but she opted for medical management. Immediately, patient was throm- bolysed with streptokinase. Later conservative treatment with continu- ous drip-infusion of nitroglycerine and enoxaparin 60 mg subcutane- ously was started. Additionally, she was administered oral metoprolol (100 mg/day), aspirin (150 mg/day), clopidogrel 75 mg, atorvastatin 80 mg, ramipril 5 mg, furosemide+spironolactone (20 mg+50 mg) and iso- sorbide mononitrate (40 mg/day). Patient was asymptomatic aſter two days. On the fourth day of admission, prior to discharge, cardiac catheteriza- tion was performed. It revealed 95% narrowing in the mid of the leſt anterior descending artery (LAD) (Figure. 2). Percutaneous coronary in- tervention was not performed as the patient refused to undergo stent im- plantation. Her clinical course was uneventful. Treadmill exercise stress testing performed 2 weeks later showed a negative result for ischemia. e results of laboratory tests are shown in Table 1. No evidence of col- lagen diseases including vasculitis or a deficiency of coagulation factor was noted. Hence leuprolide causing decreased serum level of estrogen was postulated as the causative factor (Table 1). Leuprolide was stopped, and three months later, her serum estrogen level improved to that of pre- menopausal women (35 pg/ml) along with some other tests. (Table 1) DISCUSSION Several studies have reported that young adults with acute myocardial infarction oſten angiographically show normal coronary arteries, 3 coro- nary vasospasm 4 or artherosclerosis in LAD. 5 To our knowledge, only 4 cases of cardiovascular disease secondary to leuprolide use have been re- ported in women 6-9 and this being the first case reported in Indian popu- lation. In this case, the first coronary angiography revealed near-total 99% stenosis in mid LAD unlike previous cases reported in literature where diffuse narrowing in the distal half of the LAD or coronary vaso- Leuprolide induced Myocardial Infarction ABSTRACT A 36-year-old premenopausal woman was admitted with acute myocardial infarction. The lady was being administered leuprolide, a GnRH agonist which suppresses FSH and LH which in turn decreases blood estrogen level for the treatment of uterine fibroid. Patient was initially thrombolysed with streptokinase and later treated with anticoagulants and antiangi- nals. Check coronary angiography performed on the fourth day revealed mid left anterior descending artery (LAD) 99% stenosis. Apart from mild hypertension which was controlled by lifestyle modifications there were no other coronary risk factors. It was concluded that decreased serum estrogen level caused by leuprolide could cause ischemic heart disease even in premenopausal women and caution to be exercised while using this drug. Key words: Myocardial infarction, Coronary vasospasm, Anti-estrogen, Leuprolide, Uterine fibroid. Vikas Mishra, Rajendra Kumar Bansal, Chandra Mohan Verma, Ramesh Thakur, Umeshwar Pandey, Santosh Kumar Sinha, Mohamadulla Razi, Mohammad Ahmad, Raj Pratap Singh Bharadwaj Department of Cardiology, LPS Institute of cardiology, GSVM Medical College, Kanpur, UP, INDIA. Correspondence: Dr. Vikas Mishra , MD Department of Cardiology LPS Institute of cardiology GSVM Medical College, Kanpur, UP, India. Email- dr.vikasmishra@gmail. com Ph- 07052768771 Submission Date: 21-05-2016; Revision Date: 31-08-2016; Accepted Date: 12-09-2016. DOI : 10.5530/jcdr.2016.3.9