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Case Report
Open Access Peer-reviewed

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

Jeffrey Song , Tariq Sharman
American Journal of Medical Case Reports. 2019, 7(11), 271-273. DOI: 10.12691/ajmcr-7-11-2
Received June 27, 2019; Revised August 06, 2019; Accepted August 14, 2019

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.

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.

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.
In article      View Article  PubMed
 
[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.
In article      View Article  PubMed
 
[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.
In article      View Article
 
[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.
In article      View Article
 
[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.
In article      View Article
 
[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.
In article      View Article  PubMed  PubMed
 
[7]  Tam SW, Worcel M, Wyllie M (2001). "Yohimbine: a clinical review". Pharmacology and Therapeutics. 91 (3): 239
In article      View Article
 
[8]  Morales A (March 2000). "Yohimbine in erectile dysfunction: the facts". review. International Journal of Impotence Research. 12 (Suppl 1): S70-74.
In article      View Article
 
[9]  Andersson KE (September 2001). "Pharmacology of penile erection". Review. Pharmacological Reviews. 53 (3): 417-50.
In article      
 
[10]  Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. Circulation. 2012; 126: 2020–35.
In article      View Article  PubMed
 
[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.
In article      View Article  PubMed  PubMed
 
[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.
In article      View Article  PubMed
 
[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.
In article      View Article  PubMed
 

Published with license by Science and Education Publishing, Copyright © 2019 Jeffrey Song and Tariq Sharman

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

Cite this article:

Normal Style
Jeffrey Song, Tariq Sharman. Yohimbine Induced Type II Myocardial Injury: An Underrecognized and Dangerous Adverse Effect. American Journal of Medical Case Reports. Vol. 7, No. 11, 2019, pp 271-273. http://pubs.sciepub.com/ajmcr/7/11/2
MLA Style
Song, Jeffrey, and Tariq Sharman. "Yohimbine Induced Type II Myocardial Injury: An Underrecognized and Dangerous Adverse Effect." American Journal of Medical Case Reports 7.11 (2019): 271-273.
APA Style
Song, J. , & Sharman, T. (2019). Yohimbine Induced Type II Myocardial Injury: An Underrecognized and Dangerous Adverse Effect. American Journal of Medical Case Reports, 7(11), 271-273.
Chicago Style
Song, Jeffrey, and Tariq Sharman. "Yohimbine Induced Type II Myocardial Injury: An Underrecognized and Dangerous Adverse Effect." American Journal of Medical Case Reports 7, no. 11 (2019): 271-273.
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[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.
In article      View Article  PubMed
 
[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.
In article      View Article  PubMed
 
[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.
In article      View Article
 
[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.
In article      View Article
 
[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.
In article      View Article
 
[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.
In article      View Article  PubMed  PubMed
 
[7]  Tam SW, Worcel M, Wyllie M (2001). "Yohimbine: a clinical review". Pharmacology and Therapeutics. 91 (3): 239
In article      View Article
 
[8]  Morales A (March 2000). "Yohimbine in erectile dysfunction: the facts". review. International Journal of Impotence Research. 12 (Suppl 1): S70-74.
In article      View Article
 
[9]  Andersson KE (September 2001). "Pharmacology of penile erection". Review. Pharmacological Reviews. 53 (3): 417-50.
In article      
 
[10]  Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. Circulation. 2012; 126: 2020–35.
In article      View Article  PubMed
 
[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.
In article      View Article  PubMed  PubMed
 
[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.
In article      View Article  PubMed
 
[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.
In article      View Article  PubMed