Yonsei Med J.  2016 Mar;57(2):512-517. 10.3349/ymj.2016.57.2.512.

Adverse Cardiovascular Events after a Venomous Snakebite in Korea

• Kim OH
• Lee JW
• Kim HI
• Cha K
• Kim H
• Lee KH
• Hwang SO
• Cha YS

• KMID: 2374061
• DOI: http://doi.org/10.3349/ymj.2016.57.2.512

Abstract

PURPOSE
Although cardiac involvement is an infrequently recognized manifestation of venomous snakebites, little is known of the adverse cardiovascular events (ACVEs) arising as a result of snakebite in Korea. Accordingly, we studied the prevalence of ACVEs associated with venomous snakebites in Korea and compared the clinical features of patients with and without ACVEs.
MATERIALS AND METHODS
A retrospective review was conducted on 65 consecutive venomous snakebite cases diagnosed and treated at the emergency department of Wonju Severance Christian Hospital between May 2011 and October 2014. ACVEs were defined as the occurrence of at least one of the following: 1) myocardial injury, 2) shock, 3) ventricular dysrhythmia, or 4) cardiac arrest.
RESULTS
Nine (13.8%) of the 65 patients had ACVEs; myocardial injury (9 patients, 13.8%) included high sensitivity troponin I (hs-TnI) elevation (7 patients, 10.8%) or electrocardiogram (ECG) determined ischemic change (2 patients, 3.1%), and shock (2 patient, 3.1%). Neither ventricular dysrhythmia nor cardiac arrest was observed. The median of elevated hs-TnI levels observed in the present study were 0.063 ng/mL (maximum: 3.000 ng/mL) and there was no mortality in the ACVEs group. Underlying cardiac diseases were more common in the ACVEs group than in the non-ACVEs group (p=0.017). Regarding complications during hospitalization, 3 patients (5.4%) in the non-ACVEs group and 3 patients (33.3%) in the ACVEs group developed bleeding (p=0.031).
CONCLUSION
Significant proportion of the patients with venomous snakebite is associated with occurrence of ACVEs. Patients with ACVEs had more underlying cardiac disease and bleeding complication.

Keyword

Snakebite; heart injury; troponin I; shock

MeSH Terms

Aged
Arrhythmias, Cardiac/epidemiology/*etiology
Cardiovascular Diseases/epidemiology
Electrocardiography
Emergency Service, Hospital
Female
Heart Arrest/epidemiology/*etiology
Hospitalization
Humans
Male
Middle Aged
Prevalence
Republic of Korea
Retrospective Studies
Snake Bites/*complications/diagnosis/epidemiology
Troponin I/blood
Troponin I

Reference

1. Chippaux JP. Snake-bites: appraisal of the global situation. Bull World Health Organ. 1998; 76:515–524.

2. Kasturiratne A, Wickremasinghe AR, de Silva N, Gunawardena NK, Pathmeswaran A, Premaratna R, et al. The global burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming and deaths. PLoS Med. 2008; 5:e218.

3. Agarwal R, Singh AP, Aggarwal AN. Pulmonary oedema complicating snake bite due to Bungarus caeruleus. Singapore Med J. 2007; 48:e227–e230.

4. Nayak KC, Jain AK, Sharda DP, Mishra SN. Profile of cardiac complications of snake bite. Indian Heart J. 1990; 42:185–188.

5. Jang TC, Seo YW, Lee KW. A Case of a acute myocardial infarction complicated by a snake bite. J Korean Soc Emerg Med. 2011; 22:760–763.

6. Park EJ, Yoon SK, Ahn JH, Choi SC, Kim GW, Min YG, et al. Systemic Complications occurring after Korean Venomous Snake Bite, with focus on Hematologic and Neurologic Complications. J Korean Soc Clin Toxicol. 2009; 7:90–96.

7. Dart RC, Hurlbut KM, Garcia R, Boren J. Validation of a severity score for the assessment of crotalid snakebite. Ann Emerg Med. 1996; 27:321–326.

8. World Health Organization. Worldwide prevalence of anaemia 1993-2005: WHO global database on anaemia. accessed on 2015 May 1. Available at: http://apps.who.int/iris/handle/10665/43894.

9. Gando S. The utility of a diagnostic scoring system for disseminated intravascular coagulation. Crit Care Clin. 2012; 28:373–388. vi

10. Shim JH, Son YJ, Lee SS, Park KS, Oh HB, Park YD. Ecological study on poisonous snake and investigation of the venom characteristics, snakebiting frequency in Korea. Korean J Environ Ecol. 1998; 12:58–77.

11. Karaye KM, Mijinyawa MS, Yakasai AM, Kwaghe V, Joseph GA, Iliyasu G, et al. Cardiac and hemodynamic features following snakebite in Nigeria. Int J Cardiol. 2012; 156:326–328.

12. Habib AG, Abubakar SB. Factors affecting snakebite mortality in north-eastern Nigeria. Int Health. 2011; 3:50–55.

13. Agewall S, Giannitsis E, Jernberg T, Katus H. Troponin elevation in coronary vs. non-coronary disease. Eur Heart J. 2011; 32:404–411.

14. Mahajan VS, Jarolim P. How to interpret elevated cardiac troponin levels. Circulation. 2011; 124:2350–2354.

15. Lalloo DG, Trevett AJ, Nwokolo N, Laurenson IF, Naraqi S, Kevau I, et al. Electrocardiographic abnormalities in patients bitten by taipans (Oxyuranus scutellatus canni) and other elapid snakes in Papua New Guinea. Trans R Soc Trop Med Hyg. 1997; 91:53–56.

16. Maheshwari M, Mittal SR. Acute myocardial infarction complicating snake bite. J Assoc Physicians India. 2004; 52:63–64.

17. Aravanis C, Ioannidis PJ, Ktenas J. Acute myocardial infarction and cerebrovascular accident in a young girl after a viper bite. Br Heart J. 1982; 47:500–503.

18. Blondheim DS, Plich M, Berman M, Khair G, Tzvig L, Ezri J, et al. Acute myocardial infarction complicating viper bite. Am J Cardiol. 1996; 78:492–493.

19. Tony JC, Bhat R. Acute myocardial infarction following snake bite. Trop Doct. 1995; 25:137.

20. Gaballa M, Taher T, Brodin LA, van der Linden J, O'Reilly K, Hui W, et al. Images in cardiovascular medicine. Myocardial infarction as a rare consequence of a snakebite: diagnosis with novel echocardiographic tissue Doppler techniques. Circulation. 2005; 112:e140–e142.

21. Bashir R, Jinkins J. Cerebral infarction in a young female following snake bite. Stroke. 1985; 16:328–330.

22. Frangides C, Kouni S, Niarchos C, Koutsojannis C. Hypersersensitivity and Kounis syndrome due to a viper bite. Eur J Intern Med. 2006; 17:215–216.

23. Lee BJ, Hong SI, Kim HS, Kim TH, Lee JH, Kim HJ, et al. Hematological features of coagulopathy and the efficacy of antivenin therapy for a Korean snakebite. J Korean Surg Soc. 2007; 72:18–26.

24. White J. Snake venoms and coagulopathy. Toxicon. 2005; 45:951–967.

25. Kim JS, Yang JW, Kim MS, Han ST, Kim BR, Shin MS, et al. Coagulopathy in patients who experience snakebite. Korean J Intern Med. 2008; 23:94–99.

26. Cho NS, Park J. A clinical analysis of snake bite injury. J Korean Soc Emerg Med. 1996; 7:405–414.