Energy drink (ED) consumption has been linked to several adverse event reports, but there is limited data on related cardiovascular (CV) complications. We describe clinical characteristics, ED consumption profile, co-ingestions, and results of cardiovascular testing in a series of cardiovascular event reports temporally related to ED consumption from the literature. We searched PubMed and Embase for case reports in peer-reviewed journals from January 1, 1980, to February 1, 2013, in which an acute CV event was associated temporally with ED consumption. We identified 14 eligible articles involving 15 cases (5 atrial arrhythmias, 5 ventricular arrhythmias, 1 QT prolongation, 4 ST-segment elevations). Two additional cases of cardiac arrest from our institution are included. Of these 17 cases of ED-related acute CV events (13 male cases; 15 cases aged <30 years, age range 13 to 58 years), only 1 had minor previous cardiac disease. Cardiac investigations did not reveal any predisposing cardiac abnormality in the majority of cases. Of the 11 cases related to a serious event (i.e., cardiac arrest, ventricular arrhythmia, or ST-segment elevations), 5 reported acute heavy ED consumption, 4 reported co-ingestions with alcohol or other drugs, and 2 were found to have a channelopathy. Potential mechanisms of ED-related cardiac events are reviewed. In conclusion, several adverse CV events after consuming ED have been reported in the literature. Although causality cannot be inferred from our series, physicians should routinely inquire about ED consumption in relevant cases, and vulnerable consumers such as youth should be advised that caution is warranted with heavy consumption and/or with concomitant alcohol or drug ingestion.
The rapid increase in energy drink (ED) consumption has stimulated growing public concern with adverse events related to ED consumption. The United States (US) Substance Abuse Services and Mental Health Administration has reported that over a 4-year period from 2007 to 2011, emergency department visits related to EDs more than doubled to >20,000 visits annually. Most of the adverse effects and toxicities associated with EDs have been attributed to the high caffeine content of EDs. In addition to the high caffeine content, EDs are frequently consumed by younger segments of the population who may be caffeine-naive and more prone to consume large quantities, often mixed with alcohol and other substances, increasing the risk of adverse events. EDs also contain several other ingredients that may also increase these risks. Although the US Food and Drug Administration (FDA) recently released a list of adverse event reports allegedly related to EDs, extremely limited data (product name, symptoms, and outcome) regarding the clinical characteristics of these cases and their ED consumption profile have been made available to inform clinicians about this emerging health problem. Accordingly, we systematically reviewed the available literature for cases of cardiovascular (CV) events temporally related to ED consumption. We also included 2 additional cases from our institution of cardiac arrest after ED consumption.
Methods
We performed a systematic review of the Medline and Embase databases for peer-reviewed articles published between January 1, 1980, and February 1, 2013, containing the search terms “energy drinks,” “adverse effects,” “myocardial infarction,” “cardiac arrest,” and “arrhythmia” in various combinations. The cases were independently extracted by 2 reviewers without any discrepancies. Articles were excluded if they were not related to EDs and CV disease, were physiologic or epidemiologic studies, or did not describe specific cases of an acute CV event. We included all published cases of acute CV events potentially associated to ED consumption for which sufficient clinical information was available. Case reports were excluded if they did not provide sufficient clinical details (e.g., preexisting heart disease, type of CV event) or failed to report cardiac investigations. Because the Medical Subject Heading “Energy Drinks” did not exist before June 2011, we also performed a thorough manual search of the literature to identify potential cases. Our search was limited to publications written in English, French, or Spanish.
From each eligible case, we extracted available data with regard to age and gender of the case, type of CV event, brand of ED consumed, estimated caffeine-dose ingested (as documented in the original report or calculated based on reported ED consumption and corresponding caffeine-content disclosed on product labels) within 24 hours of event, co-ingestions with alcohol or other substances, preexisting CV disease, and results of CV investigations. We considered an estimated acute ingestion of ≥480 mg of caffeine within 8 hours as “acute heavy consumption” because this corresponds to drinking >3 cans or bottles (16 oz) of several popular EDs in a short time period. We also characterized “chronic heavy consumption” as ≥200 mg/day of caffeine from EDs over ≥1 weeks. A serious CV event was defined as a cardiac arrest, ventricular arrhythmia, or ST-segment elevation.
Results
Our search identified 657 articles. In total, 7 articles containing 8 cases met our inclusion criteria on the initial search (see Figure 1 ). Seven additional articles were identified on the manual search. We also included 2 additional cases from our institution (McGill University, Montreal, Canada). A detailed description of each case is available in the online supplementary materials . Table 1 contains a list of all 17 cases (15 cases from the literature and 2 cases from our institution).
| Case | Year (Reference) | Presentation | Age (yrs)/Sex | ED and Co-Ingestions | Caffeine Consumed (mg) | Cardiac Investigations | Cardiac Abnormalities Identified ∗ | Outcome |
|---|---|---|---|---|---|---|---|---|
| 1 | 2011 | AF | 16 M | Red Bull | Unknown | ECG TTE | None | Conversion to SR |
| 2 | 2011 | AF | 14 M | Red Bull; vodka | Unknown | ECG TTE | None | Conversion to SR |
| 3 | 2012 | AF | 13 M | — | 85 | ECG TTE | None | Conversion to SR |
| 4 | 2007 | AF | 58 M | — | 575 | ECG TTE Cath | EF 45% ≥ 65% | Conversion to SR |
| 5 | 2008 | SVT | 23 F | GNC Speed Shot | 250 | ECG | None | Conversion to SR |
| 6 | 2012 | Prolonged QT | 13 F | — | 160 | ECG EST Gen | LQTS1 (KCNQ1) | QT interval ↓ |
| 7 | 2012 | TdP | 22 F | — | 480 | ECG TTE Cath Gen | LQTS1 (KCNQ1) | Aborted SD |
| 8 | 2001 | VF | 25 F | Race Energy Blast | 570 | ECG Autopsy | MVP | SD |
| 9 | 2009 | VF | 28 M | — | 640 | ECG TTE Cath | EF ↓ ≥ nl | Aborted SD |
| 10 | 2013 (case 1) | VF | 19 M | Monster; marijuana | 160 | ECG TTE Cath EPS ‡ | None | Aborted SD |
| 11 | 2012 | VF | 24 M | Red Bull; vodka | 80 | ECG | Brugada type 1 | Aborted SD |
| 12 | 2013 (case 2) | Cardiac arrest † | 57 M | NOS | 1,300 | ECG TTE Cath | LVH with RWMA | Aborted SD |
| 13 | 2012 | VT/SVT | 24 M | — | — | ECG TTE Cath MRI | EF ↓ ≥ nl | Conversion to SR |
| 14 | 2012 | ST elevation | 17 M | Red Bull, Monster | 560–800 | ECG TTE Nuc | EF ↓ ≥ nl | Resolution |
| 15 | 2012 | ST elevation | 24 M | XL; MDMA | 1,600 | ECG | None | SD |
| 16 | 2011 | ST elevation | 19 M | Red Bull | 160–240 | ECG TTE Cath | None | Resolution |
| 17 | 2012 | ST elevation | 24 M | —; vodka | — | ECG TTE Cath | Acute thrombosis | Emergent CABG |
∗ Only abnormal results are listed; other available investigations were normal.
† Initial rhythm strip before defibrillation from emergency medical services was not documented.
‡ Provocative testing with procainamide and epinephrine was performed.
Results
Our search identified 657 articles. In total, 7 articles containing 8 cases met our inclusion criteria on the initial search (see Figure 1 ). Seven additional articles were identified on the manual search. We also included 2 additional cases from our institution (McGill University, Montreal, Canada). A detailed description of each case is available in the online supplementary materials . Table 1 contains a list of all 17 cases (15 cases from the literature and 2 cases from our institution).
| Case | Year (Reference) | Presentation | Age (yrs)/Sex | ED and Co-Ingestions | Caffeine Consumed (mg) | Cardiac Investigations | Cardiac Abnormalities Identified ∗ | Outcome |
|---|---|---|---|---|---|---|---|---|
| 1 | 2011 | AF | 16 M | Red Bull | Unknown | ECG TTE | None | Conversion to SR |
| 2 | 2011 | AF | 14 M | Red Bull; vodka | Unknown | ECG TTE | None | Conversion to SR |
| 3 | 2012 | AF | 13 M | — | 85 | ECG TTE | None | Conversion to SR |
| 4 | 2007 | AF | 58 M | — | 575 | ECG TTE Cath | EF 45% ≥ 65% | Conversion to SR |
| 5 | 2008 | SVT | 23 F | GNC Speed Shot | 250 | ECG | None | Conversion to SR |
| 6 | 2012 | Prolonged QT | 13 F | — | 160 | ECG EST Gen | LQTS1 (KCNQ1) | QT interval ↓ |
| 7 | 2012 | TdP | 22 F | — | 480 | ECG TTE Cath Gen | LQTS1 (KCNQ1) | Aborted SD |
| 8 | 2001 | VF | 25 F | Race Energy Blast | 570 | ECG Autopsy | MVP | SD |
| 9 | 2009 | VF | 28 M | — | 640 | ECG TTE Cath | EF ↓ ≥ nl | Aborted SD |
| 10 | 2013 (case 1) | VF | 19 M | Monster; marijuana | 160 | ECG TTE Cath EPS ‡ | None | Aborted SD |
| 11 | 2012 | VF | 24 M | Red Bull; vodka | 80 | ECG | Brugada type 1 | Aborted SD |
| 12 | 2013 (case 2) | Cardiac arrest † | 57 M | NOS | 1,300 | ECG TTE Cath | LVH with RWMA | Aborted SD |
| 13 | 2012 | VT/SVT | 24 M | — | — | ECG TTE Cath MRI | EF ↓ ≥ nl | Conversion to SR |
| 14 | 2012 | ST elevation | 17 M | Red Bull, Monster | 560–800 | ECG TTE Nuc | EF ↓ ≥ nl | Resolution |
| 15 | 2012 | ST elevation | 24 M | XL; MDMA | 1,600 | ECG | None | SD |
| 16 | 2011 | ST elevation | 19 M | Red Bull | 160–240 | ECG TTE Cath | None | Resolution |
| 17 | 2012 | ST elevation | 24 M | —; vodka | — | ECG TTE Cath | Acute thrombosis | Emergent CABG |
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