Vaping Associated Cardiac Arrest at School in a Teenager with Anomalous Left Coronary Artery

Abstract

The prevalence of electronic cigarette use is increasing at an astonishing pace, particularly in the teenage population. While at school, a healthy 13-year-old male experienced a sudden cardiac arrest after vaping multiple times throughout the day. Workup revealed an anomalous left coronary artery originating from the right sinus of Valsalva. Given this patient’s underlying anomalous left coronary artery, we suspect that sympathoexcitatory and arrhythmogenic effects of high dose nicotine from vaping led to his cardiovascular collapse. This is the first published case report of a vaping associated cardiac arrest in a patient of this age.

Introduction

Vaping nicotine containing products is a growing epidemic in teenagers with up to five million using electronic cigarettes (e-cigarettes).¹ With a rise in vaping and high dose nicotine exposure, there have been reported cases of E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI) in the pediatric population. The acute and chronic systemic effects of vaping, however, are not well known or reported in pediatrics. Here we present a case of a cardiac arrest in a 13-year-old, with an undiagnosed anomalous left coronary artery, that occurred shortly after vaping while in school. Written HIPAA authorization was obtained from the family for the purpose of this report. This is the first published case report of a vaping associated cardiac arrest in a patient of this age.

Case Presentation

While at school, an otherwise healthy 13-year-old male with no significant past-medical history, experienced a sudden cardiac arrest. At the beginning of gym class, he developed a sensation of heavy pressure in his chest that progressed to lightheadedness and dizziness. The patient then had a witnessed collapse followed by initiation of cardiopulmonary resuscitation (CPR). The patient required several rounds of CPR with two defibrillation shocks from the automated external defibrillator (AED). His heart rhythm was alternating between ventricular fibrillation and polymorphic ventricular tachycardia. After emergency medical services arrived, CPR was continued until the patient had return of spontaneous circulation. On further investigation, it was noted that the patient had been vaping nicotine containing products immediately prior to going to gym class, as well as vaping one to two times per hour throughout the day.

Upon arrival to the hospital, an echocardiogram and CT angiogram revealed an anomalous left coronary artery originating from the right sinus of Valsalva with an intramural segment (Figure 1). A stress test did not reveal inducible ectopy or ischemic changes. A urine drug screen was negative, except for nicotine and cotinine, a metabolite of nicotine. The patient was stable from a respiratory standpoint excluding a diagnosis of EVALI. During his hospital stay, the patient underwent repair of his anomalous right origin of the left coronary artery by unroofing and resuspension in the left commissure. The surgical procedure went as planned and was uneventful. The patient arrived in the cardiac intensive care unit intubated and sedated on dexmedetomidine and morphine, as well as a milrinone infusion. An epinephrine infusion was subsequently started for hypotension thought to be from vasodilation. The patient was extubated later that day, and all vasoactive medications were weaned off overnight. He was transferred from the intensive care unit to an inpatient floor room the following day.

Figure 1.

This computed tomography (CT) angiogram shows the right coronary artery coming off towards the left side of the image and the anomalous left coronary artery coming off towards the right side of image branching into the left anterior descending and left circumflex arteries.

The patient was later discharged with a wearable cardiac defibrillator device. Genetic testing was inconclusive with no additional recommendations. The patient followed up with cardiology a month later, and a stress test was found to be normal. The patient was cleared to return to sports participation, and it was emphasized that he refrains from vaping nicotine containing products in the future.

Discussion

Since 2011, the prevalence of e-cigarette use has increased at an astonishing pace, including the teenage population. Popular vaping devices are made by JUUL® and Puff Bar®. Due to their discrete and compact profile, these products are used inside and outside of schools, with increased use in school bathrooms and even in classrooms.² Between 2011 and 2015, e-cigarette use climbed from 0.6% to 5.3% in middle school children in the United States and from 1.5% to 16% in high schoolers.³

Since 2014, e-cigarettes are the most widely used tobacco product among middle and high schoolers.² Another source identifies 2014 as the “breakpoint” from traditional cigarette smoking in children and the rapid crescendo of the use of e-cigarette products.⁴ From 2017 to 2018, e-cigarette use increased by 77.8% in high schoolers. In 2019, a self-report survey completed by over 19,000 middle and high school students found that 10.5% of middle school students and 27.5% of high school students use e-cigarettes.¹ This sharp incline in vaping is not without potential medical consequences, especially from high levels of nicotine.

In general, sympathetic activation is the most important physiological effect of nicotine. Plasma nicotine levels after vaping are dependent on the generation of electronic cigarette device being used, with most studies looking at the cardiovascular effects after using a first- or second-generation device. ⁵ The later generation devices like the JUUL® Pod-Mods use nicotine salts instead of alkalinized nicotine which is a more effective delivery method with plasma nicotine levels approaching that of tobacco cigarettes.⁶ Newer vaping devices also contain higher nicotine concentrations with up to a 5% nicotine solution (>50mg/mL), compared to older devices that ranged from 1 to 3% nicotine concentration.⁷ Despite a lack of studies using the later generation of devices, studies have shown an acute increase in heart rate and blood pressure which occurred within five to ten minutes secondary to a release of catecholamines. ⁸ In addition, vaping electronic cigarettes containing nicotine were found to cause electrocardiogram changes specifically increasing the (T_peak to T_end)/QT ratio, causing abnormal ventricular repolarization which is associated with an increased risk of sudden death.⁹ It is important to note that nicotine use has been associated with coronary vasospasm as well.¹⁰

The prevalence of anomalous left coronary artery (ALCA) arising from the right sinus of Valsalva is extremely rare (0.03%) and is rarely identified in asymptomatic individuals while alive. ¹¹ In ALCA, death often occurs during exercise or with exertion. The proposed mechanism suggests that episodic myocardial ischemia with exertion can result in a lethal arrhythmia and subsequent death. Given this patient’s underlying ALCA, we suspect that sympathoexcitatory and arrhythmogenic effects of high dose nicotine via vaping could have led to his cardiovascular collapse at the beginning of gym class. It’s noteworthy that the vaping cartridges used by this patient prior to his cardiac arrest did not contain tetrahydrocannabinol (THC), and the cartridges were not tampered with prior to use. In THC-containing vaping products, vitamin E acetate is a common and harmful additive, which has been associated with EVALI. ¹²

Conclusion

The effects of e-cigarette use on the cardiovascular system are not well known in the pediatric population. Based on the known adverse effects of nicotine, we suspect that it was the main culprit that caused our patient to suffer a cardiac arrest in the setting of his undiagnosed anomalous left coronary artery. However, due to lack of uniform regulation, the constituents and their concentration in e-cigarettes can vary from product to product. We propose that the adolescent community can benefit from studies looking at the acute and chronic adverse effects of each individual component on the cardiovascular system.