A case of ST elevation myocardial infarction precipitated by methylphenidate therapy for gait freeze

Background: Parkinson's disease affects 1% of the population older than 60 years. Motor symptoms can be difficult to treat in end-stage disease, leading to the use of therapies with less favourable adverse effect profiles.Aim: To promote awareness of the risks associated with the off-label use of methylphenidate for hypokinesia in Parkinson's disease patients with cardiovascular risk factors.Clinical details: A 70-year-old Caucasian non-smoking male presented to the hospital with chest pain and inferior ST segment elevation 2 months after commencing methylphenidate for gait hypokinesia. His past medical history was significant for end-stage Parkinson's disease with associated psychosis, and ischaemic heart disease with previous myocardial infarction. Relevant therapies included levodopa, benserazide, amantadine, pramipexole, quetiapine, atorvastatin and perindopril.Outcomes: The patient received a drug eluting stent to the circumflex artery, followed by a staged percutaneous coronary intervention to the left anterior descending artery. Methylphenidate was discontinued on day 2 post myocardial infarction in light of published data indicating an increased risk of myocardial infarction with methylphenidate use. Methylphenidate is known to stimulate catecholamine release, thereby increasing the risk of ischaemic cardiovascular events by increasing myocardial oxygen demand.Conclusion: This is the first reported case to describe methylphenidate use in Parkinson's disease complicated by a myocardial infarction. This case, in conjunction with other published literature, suggests that the use of methylphenidate for this novel indication must be carefully considered for each individual, and avoided in those with cardiovascular risk factors or known ischaemic heart disease.