Sumatriptan is a selective 5-hydroxytryptamine agonist efficacious in the treatment of migraine headache. Although chest discomfort associated with use of this product is common, cardiovascular complications are rare. We describe a woman who had cardiac arrest and a right ventricular myocardial infarction immediately after subcutaneous injection of sumatriptan.

A 48-year-old surgically postmenopausal woman with a history of type 2 diabetes mellitus and tobacco abuse presented to our ambulatory care clinic with a migraine headache. She was given 6 mg of sumatriptan subcutaneously and within 10 minutes had chest tightness and nausea that persisted despite administration of meperidine and promethazine. Shortly thereafter, she collapsed and was found pulseless and apneic; the initial cardiac rhythm was polymorphic ventricular tachycardia. She was resuscitated after prolonged cardiopulmonary resuscitation and multiple direct-current countershocks; the initial postresuscitation electrocardiogram showed diffuse ST-segment elevation. Subsequent electrocardiograms obtained minutes later showed inferior and right precordial ST-segment elevation. Emergent coronary angiography showed left dominant circulation, moderate left coronary disease, and a proximally occluded nondominant right coronary artery. Because of the small caliber of the vessel, intervention was not attempted. Over the next several days, the patient required large volumes of normal saline and early inotropic support to maintain cardiac output, but she gradually stabilized. The creatine phosphokinase level peaked at 2881 U/L (MB fraction, 41) with a troponin I level of 31.9 ng/mL. The patient was discharged approximately 1 week later with mild cognitive defects and new decreased visual acuity attributed to ischemic optic neuropathy.

Although sumatriptan exerts its therapeutic effect through cerebral vasoconstriction, studies have also documented vasoconstriction in the coronary, pulmonary, and systemic vasculature after subcutaneous injection [1]. Despite the generalized vasoconstrictive nature of this agent, few reports have associated sumatriptan with myocardial infarction. In two cases, no enzymatic evidence of myocardial necrosis was reported [2, 3], and coronary angiography revealed either normal coronary arteries [2] or minimal luminal irregularities [3]. In a third report, a 47-year-old man presented with an inferior myocardial infarction temporally associated with sumatriptan use; angiography was not performed [4]. In a fourth case, a 35-year-old woman with severe coronary artery disease and history of cocaine abuse had cardiac arrest shortly after use of subcutaneous sumatriptan with subsequent evidence of myocardial necrosis [5].

In contrast to previous associations, our patient developed symptoms immediately after sumatriptan injection, acute myocardial infarction was documented by both ST-segment elevation and enzymatic evidence of myocardial necrosis, and acute coronary angiography showed coronary occlusion in the distribution of electrocardiographic changes.

In light of this report and others [2-5] and the previously documented coronary vasoconstrictive properties of this medication [1], sumatriptan is contraindicated in patients with coronary artery disease or vasospastic angina. Physicians should carefully question patients about risk factors for coronary artery disease before prescribing this drug.