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receptor agonist that is effective in the acute treatment of migraine&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The drug is rapidly absorbed when orally administered&#44; has good bioavailability &#40;50&#37; compared to 14&#37; for sumatriptan&#41; and a long half-life&#44; which enhances its ability to prevent recurrent headaches&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Serious adverse cardiac events including acute myocardial infarction due to coronary vasospasm&#44; arrhythmias and death have been reported after the administration of 5-HT<span class="elsevierStyleInf">1</span> agonists&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In the literature&#44; symptoms of chest pain&#44; neck tightness and chest pressure have been widely described in patients taking 5-HT<span class="elsevierStyleInf">1</span> agonists&#44; but few serious cardiovascular events such as myocardial infarction have been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;11</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 53-year-old male patient with a medical history significant for hyperlipidemia&#44; paroxysmal atrial fibrillation and migraines with visual aura &#40;one or two attacks a month&#41; presented to the emergency department &#40;ED&#41; complaining of chest pain&#46; On the previous afternoon&#44; the patient experienced a typical migraine attack and took 40 mg of eletriptan&#44; which partially relieved his headache&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">On the following morning&#44; given the persistence of his symptoms&#44; he decided to take two 40-mg eletriptan tablets &#40;maximum recommended single dose 40 mg or 80 mg in a 24-hour period&#41;&#46; Four hours later&#44; while driving home from work&#44; he developed sudden-onset midsternal chest pain&#44; nonradiating and severe in intensity&#44; which led him to seek medical attention&#46; He denied having similar symptoms in the past&#46; He was a lifelong nonsmoker and exercised regularly&#46; He had no personal history of diabetes or hypertension&#46; There was also no family history of premature coronary artery disease&#46; On admission he was still in pain&#46; The respiratory and cardiovascular examinations were unremarkable&#46; Neurological examination revealed no neurological deficits&#46; The first electrocardiogram &#40;ECG&#41; obtained in the ED showed sinus bradycardia with a heart rate of 55 bpm&#44; without ST-T wave changes&#46; Initial and peak troponin were 1&#46;18 ng&#47;ml and 8&#46;36 ng&#47;ml&#44; respectively&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Coronary angiography &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1 and 2</a>&#41; was performed 12 hours after his presentation and showed normal coronary arteries&#46; Left ventriculography &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41; revealed mild posterobasal hypokinesis&#46; Left ventricular ejection fraction was mildly decreased&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">To the best of our knowledge this is the first reported myocardial infarction attributable to eletriptan overdose in a patient without coronary artery disease&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Our patient presented to the ED complaining of chest pain associated with elevated cardiac biomarkers four hours after taking eletriptan&#46; He was diagnosed with normal coronary arteries by coronary angiography 12 hours after admission&#46; We believe this case implies a causal association between eletriptan and myocardial infarction&#44; considering the timing of both drug intake and symptom onset&#46; It is important to recall that the maximum recommended single dose of eletriptan is 40 mg or 80 mg in a 24-hour period&#44; so our patient clearly overdosed on this drug&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The vast majority of reported triptan-related coronary events have occurred after intake of sumatriptan&#44; zolmitriptan<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> or tegaserod&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Eletriptan is a potent 5HT<span class="elsevierStyleInf">1D</span>&#47;<span class="elsevierStyleInf">1B</span> receptor agonist which in animal models induces coronary constriction at a dose four times higher than sumatriptan&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Because of its higher selectivity for non-coronary vascular beds&#44; eletriptan is considered to be the agonist of choice in patients with cardiovascular risk factors but no overt coronary artery disease&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Muir et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> assessed the effects of intravenous eletriptan on the systemic&#44; pulmonary and coronary circulation in patients without coronary artery disease undergoing cardiac catheterization&#46; One patient experienced marked segmental right coronary artery constriction during drug infusion&#46; Although this episode was associated with chest pain&#44; no electrocardiographic abnormalities were detected&#44; as in our patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In the same study the authors claimed the chest pain could have resulted from catheter irritation&#44; however we believe such an event occurring in the setting of an infusion of a well-known coronary vasoconstrictor drug is worrying and its potential to cause coronary vasospasm should not be disregarded&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">It is important to identify patients at risk for dangerous cardiovascular events&#46; Various screening tests&#44; including electrocardiogram&#44; nuclear stress test and stress echocardiography&#44; have been proposed to assess cardiac risk prior to starting triptan therapy&#46; However&#44; no definite test has been standardized since the usefulness of assessing cardiovascular risk in asymptomatic patients with low pre-test probability of vasospastic phenomena is probably very limited&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Our case also highlights the importance of educating patients not to exceed the prescribed dose as well as counseling them regarding early identification of angina symptoms if on triptans&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">A new onset of chest pain in the setting of triptan use must alert patients to seek immediate medical attention and dissuade them from continuing to take increasing doses of triptans&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We report the case of a 53-year-old male patient with a medical history significant for paroxysmal atrial fibrillation&#44; migraines with visual aura and non-obstructive coronary artery disease&#44; who sustained a non-ST-elevation myocardial infarction a few hours after taking eletriptan as abortive therapy for migraine headaches&#46; We believe this case implies a causal association between eletriptan and myocardial infarction&#44; considering the timing of both drug intake and symptom onset&#46; To the best of our knowledge this is the first reported myocardial infarction attributable to eletriptan overdose in a patient without obstructive coronary artery disease&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Relatamos o caso de um doente de 53 anos de idade com uma hist&#243;ria m&#233;dica passada de fibrilha&#231;&#227;o auricular&#44; enxaqueca com aura visual e doen&#231;a coron&#225;ria n&#227;o obstrutiva que culminou em enfarte agudo do mioc&#225;rdio poucas horas ap&#243;s toma de eletriptano como terapia abortiva para enxaqueca com aura&#46; Dada a rela&#231;&#227;o temporal entre a ingest&#227;o do eletriptano e o in&#237;cio dos s&#237;ntomas&#44; os autores defendem um nexo de causualidade entre a sobredosagem de eletriptano e a s&#237;ndrome coron&#225;ria aguda&#46; Este &#233; o primeiro caso descrito de enfarte agudo do mioc&#225;rdio ap&#243;s sobredosagem de eletriptano num doente sem doen&#231;a coron&#225;ria obstrutiva&#46;</p>"
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