Significance of hypomagnesemia in cardiovascular disease
- Buddhadeb Dawn, MD
Buddhadeb Dawn, MD
- Maureen and Marvin Dunn Professor
- University of Kansas Medical Center
- Alan S L Yu, MB, BChir
Alan S L Yu, MB, BChir
- Harry Statland and Solon Summerfield Professor of Medicine
- University of Kansas Medical Center
Mild hypomagnesemia is a common electrolyte abnormality , particularly in the elderly who may have increased urinary magnesium losses due to diuretic therapy or interstitial renal disease. Whether this abnormality should be treated or prevented with prophylactic magnesium administration is unclear. The major concern is whether mild magnesium depletion predisposes to cardiac arrhythmias [2,3]. There are conflicting data as to whether this occurs in otherwise healthy subjects. A report on over 3000 patients from the Framingham Heart Study suggests that how arrhythmia is defined is an important determinant . No association with hypomagnesemia was noted for more than 10 ventricular premature complexes (VPCs) per hour or for repetitive VPCs. There was, however, an increased risk of complex or frequent (≥30/hour) VPCs with reductions in the plasma magnesium concentration of 0.16 meq/L (0.2 mg/dL or 0.08 mmol/L) or more. The formulas to convert between these units can be found elsewhere. (See "Regulation of magnesium balance".)
Thus, attempts have been made to identify those patients who might be at risk. The data suggest that this might occur when hypomagnesemia occurs in the setting of an acute ischemic event, congestive heart failure, torsades de pointes, after cardiopulmonary bypass, or in the acutely ill patient in the intensive care unit.
The mechanisms underlying the possible association between hypomagnesemia and arrhythmias are at present unknown. Arrhythmias could be due to concurrent hypokalemia, hypomagnesemia itself, or both [2,3]. Magnesium regulates several cardiac ion channels, including the calcium channel and outward potassium currents through the delayed rectifier . Lowering the cytosolic magnesium concentration in magnesium depletion will markedly increase these outward currents, shortening the action potential and increasing susceptibility to arrhythmias.
ACUTE ISCHEMIC HEART DISEASE
Patients with acute myocardial infarction who have mild hypomagnesemia appear to have a two- to threefold increase in the frequency of ventricular arrhythmias in the first 24 hours when compared with those with normal plasma magnesium levels [6,7]. Uncontrolled studies suggest that the administration of intravenous magnesium at this time can reduce the frequency of potentially fatal ventricular arrhythmias [8,9].
A relationship has also been found between the plasma magnesium concentration and ventricular arrhythmias occurring in the second or third week after myocardial infarction. In one study, for example, the mean plasma magnesium concentration was 1.83 mg/dL (0.76 mmol/L) in patients with no abnormal rhythms, 1.68 mg/dL (0.7 mmol/L) in those with multifocal ventricular premature complexes (VPCs), and 1.55 mg/dL (0.65 mmol/L) in those with unsustained ventricular tachycardia . Thirteen patients with complex arrhythmias and hypomagnesemia received intravenous magnesium over 24 hours; a normal rhythm was restored in ten.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Schimatschek HF, Rempis R. Prevalence of hypomagnesemia in an unselected German population of 16,000 individuals. Magnes Res 2001; 14:283.
- Millane TA, Ward DE, Camm AJ. Is hypomagnesemia arrhythmogenic? Clin Cardiol 1992; 15:103.
- Gettes LS. Electrolyte abnormalities underlying lethal and ventricular arrhythmias. Circulation 1992; 85:I70.
- Tsuji H, Venditti FJ Jr, Evans JC, et al. The associations of levels of serum potassium and magnesium with ventricular premature complexes (the Framingham Heart Study). Am J Cardiol 1994; 74:232.
- Agus ZS, Morad M. Modulation of cardiac ion channels by magnesium. Annu Rev Physiol 1991; 53:299.
- Dyckner T. Serum magnesium in acute myocardial infarction. Relation to arrhythmias. Acta Med Scand 1980; 207:59.
- Kafka H, Langevin L, Armstrong PW. Serum magnesium and potassium in acute myocardial infarction. Influence on ventricular arrhythmias. Arch Intern Med 1987; 147:465.
- Rasmussen HS, Suenson M, McNair P, et al. Magnesium infusion reduces the incidence of arrhythmias in acute myocardial infarction. A double-blind placebo-controlled study. Clin Cardiol 1987; 10:351.
- Abraham AS, Rosenmann D, Kramer M, et al. Magnesium in the prevention of lethal arrhythmias in acute myocardial infarction. Arch Intern Med 1987; 147:753.
- Ceremuzyński L, Van Hao N. Ventricular arrhythmias late after myocardial infarction are related to hypomagnesemia and magnesium loss: preliminary trial of corrective therapy. Clin Cardiol 1993; 16:493.
- Magnesium in Coronaries (MAGIC) Trial Investigators. Early administration of intravenous magnesium to high-risk patients with acute myocardial infarction in the Magnesium in Coronaries (MAGIC) Trial: a randomised controlled trial. Lancet 2002; 360:1189.
- Cooper HA, Dries DL, Davis CE, et al. Diuretics and risk of arrhythmic death in patients with left ventricular dysfunction. Circulation 1999; 100:1311.
- Eichhorn EJ, Tandon PK, DiBianco R, et al. Clinical and prognostic significance of serum magnesium concentration in patients with severe chronic congestive heart failure: the PROMISE Study. J Am Coll Cardiol 1993; 21:634.
- Adamopoulos C, Pitt B, Sui X, et al. Low serum magnesium and cardiovascular mortality in chronic heart failure: a propensity-matched study. Int J Cardiol 2009; 136:270.
- Ceremuzyński L, Gebalska J, Wolk R, Makowska E. Hypomagnesemia in heart failure with ventricular arrhythmias. Beneficial effects of magnesium supplementation. J Intern Med 2000; 247:78.
- Fuentes JC, Salmon AA, Silver MA. Acute and chronic oral magnesium supplementation: effects on endothelial function, exercise capacity, and quality of life in patients with symptomatic heart failure. Congest Heart Fail 2006; 12:9.
- Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction). J Am Coll Cardiol 2004; 44:671.
- Canadian Cardiovascular Society, American Academy of Family Physicians, American College of Cardiology, et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2008; 51:210.
- Banai S, Tzivoni D. Drug therapy for torsade de pointes. J Cardiovasc Electrophysiol 1993; 4:206.
- Inoue S, Akazawa S, Nakaigawa Y, et al. Changes in plasma total and ionized magnesium concentrations and factors affecting magnesium concentrations during cardiac surgery. J Anesth 2004; 18:216.
- Denny JT, Pantin E, Chiricolo A, et al. Lower incidence of hypo-magnesemia in surgical intensive care unit patients in 2011 versus 2001. J Clin Med Res 2015; 7:253.
- Cheungpasitporn W, Thongprayoon C, Kittanamongkolchai W, et al. Proton pump inhibitors linked to hypomagnesemia: a systematic review and meta-analysis of observational studies. Ren Fail 2015; 37:1237.
- Chernow B, Bamberger S, Stoiko M, et al. Hypomagnesemia in patients in postoperative intensive care. Chest 1989; 95:391.
- Rubeiz GJ, Thill-Baharozian M, Hardie D, Carlson RW. Association of hypomagnesemia and mortality in acutely ill medical patients. Crit Care Med 1993; 21:203.
- Chiuve SE, Sun Q, Curhan GC, et al. Dietary and plasma magnesium and risk of coronary heart disease among women. J Am Heart Assoc 2013; 2:e000114.
- Gartside PS, Glueck CJ. The important role of modifiable dietary and behavioral characteristics in the causation and prevention of coronary heart disease hospitalization and mortality: the prospective NHANES I follow-up study. J Am Coll Nutr 1995; 14:71.
- Liao F, Folsom AR, Brancati FL. Is low magnesium concentration a risk factor for coronary heart disease? The Atherosclerosis Risk in Communities (ARIC) Study. Am Heart J 1998; 136:480.
- Del Gobbo LC, Imamura F, Wu JH, et al. Circulating and dietary magnesium and risk of cardiovascular disease: a systematic review and meta-analysis of prospective studies. Am J Clin Nutr 2013; 98:160.
- Shechter M, Sharir M, Labrador MJ, et al. Oral magnesium therapy improves endothelial function in patients with coronary artery disease. Circulation 2000; 102:2353.
- Song Y, Manson JE, Cook NR, et al. Dietary magnesium intake and risk of cardiovascular disease among women. Am J Cardiol 2005; 96:1135.
- Khan AM, Lubitz SA, Sullivan LM, et al. Low serum magnesium and the development of atrial fibrillation in the community: the Framingham Heart Study. Circulation 2013; 127:33.