title: Cardiac rehabilitation participant with sickle cell trait and statin-related hepatotoxicity: a case report.
abstract: OBJECTIVE
  Exercise recommendations for patients with sickle cell trait (SCT) and myocardial infarction (MI) are limited. This case report describes such a patient, who subsequently participated in cardiac rehabilitation (CR).
  
  
  METHODS
  Patient experienced sudden intense chest pressure and shortness of breath while singing in church. Electrocardiogram and cardiac enzymes confirmed acute ST elevation MI. Laboratory tests indicated hyperlipidemia and elevated liver enzyme levels >4 times the upper normal limit (UNL). Day 40 post-MI, the patient returned to the hospital complaining of daily chest discomfort, atypical for angina pectoris. Following an unremarkable stress test result, the patient was encouraged to proceed with CR. Patient made regular progress through CR, although continued to experience paroxysmal chest discomfort away from CR, which he denied having during exercise. On day 75, his lipid profile met recommended targets while taking atorvastatin, but with liver enzymes >38 times UNL. Atorvastatin was discontinued at day 85, to which his enzymes responded appropriately, but by day 165, hyperlipidemia had returned. Rosuvastatin was started but was discontinued (day 197), with liver enzymes 6 times UNL. He continued CR without lipid therapy but at CR completion, the lipid panel did not meet targets. However, fitness and social indices improved significantly, although he occasionally still experienced chest pain, but with lesser frequency and intensity, and never with exercise.
  
  
  CONCLUSIONS
  CR in a patient with SCT, MI, and statin-related hepatotoxicity requires several specific considerations. Although SCT-exercise associated deaths are described in the literature, this case suggests that such patients can benefit from CR and can exercise safely.
authors.affiliation: Cardiac Wellness and Rehabilitation Centre, Trillium Health Centre, Toronto, Ontario, Canada. jkato@thc.on.ca
authors.forename: John-David
authors.initials: JD
authors.lastname: Kato
authors.forename: Cheng Tao
authors.initials: CT
authors.lastname: Wang
mesh_terms: D000924:Anticholesteremic Agents / Q000009:adverse effects*; D056486:Chemical and Drug Induced Liver Injury; D002637:Chest Pain; D004417:Dyspnea; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000009:adverse effects*; D008099:Liver / Q000378:metabolism; D008107:Liver Diseases / Q000209:etiology*; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000473:pathology*; D012307:Risk Factors; D012805:Sickle Cell Trait / Q000473:pathology*
chemical_list: D000924:Anticholesteremic Agents; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors