Connect
MJA
MJA

Bradycardia in a patient taking black cohosh

Scott C McKenzie and Atifur Rahman
Med J Aust 2010; 193 (8): 479-481.

Cimicifuga racemosa, better known as black cohosh, has been widely used in Western cultures as a herbal treatment for relieving symptoms of menopause. It has previously been linked to cases of liver toxicity. We report a case of reversible complete heart block in a woman who had recently begun taking a herbal supplement containing black cohosh. We review the known side effect profile of black cohosh and its relationship to our case.

In April 2009, a 59-year-old woman presented to a hospital emergency department after experiencing three episodes of syncope. She had never experienced cardiac ischaemic symptoms and there was no identifiable precipitant for a vasovagal event. She had no history of thyroid disease, hypertension, hyperlipidaemia or diabetes. Her personal and family medical histories were unremarkable, and she was a lifelong non-smoker and non-drinker. She had no recent febrile illness. She took no regular medications, but 2 weeks earlier had commenced taking one tablet daily of Remifemin (Schaper & Brümmer, Salzgitter, Germany; distributed by SciNat Australia, Gold Coast, Qld), a herbal preparation for the alleviation of menopausal symptoms.

Please login with your free MJA account to view this article in full

  • Scott C McKenzie1
  • Atifur Rahman2

  • 1 Prince Charles Hospital, Brisbane, QLD.
  • 2 Gold Coast Hospital, Gold Coast, QLD.


Competing interests:

None identified.

  • 1. Briese V, Stammwitz U, Friede M, Henneicke-von Zepelin HH. Black cohosh with or without St. John’s wort for symptom-specific climacteric treatment — results of a large-scale, controlled, observational study. Maturitas 2007; 57: 405-414.
  • 2. Leach MJ, Moore V. Black cohosh (Cimicifuga spp.) for menopausal symptoms (protocol). Cochrane Database Syst Rev 2008; (3): CD007244. doi: 10.1002/14651858.CD007244.
  • 3. Borrelli F, Ernst E. Black cohosh (Cimicifuga racemosa): a systematic review of adverse events. Am J Obstet Gynecol 2008; 199: 455-466.
  • 4. Borelli F, Izzo AA, Ernst E. Pharmacological effects of Cimicifuga racemosa. Life Sci 2003; 73: 1215-1229.
  • 5. Mahady GB, Low Dog T, Barrett ML, et al. United States Pharmacopeia review of the black cohosh case reports of hepatotoxicity. Menopause 2008; 15 (4 Pt 1): 628-638.
  • 6. European Medicines Agency Committee on Herbal Medicinal Products. Annex 1: Assessment of case reports connected to herbal medicinal products containing Cimicifugae racemosae rhizoma (black cohosh, root). London: EMEA, 8 May 2007. http://www.emea.europa.eu/pdfs/human/hmpc/26925806en.pdf (accessed Sep 2009).
  • 7. Therapeutic Goods Administration Adverse Drug Reactions Advisory Committee. Hepatotoxicity with black cohosh. Aust Adverse Drug React Bull 2006; 25 (2). http://www.tga.gov.au/adr/aadrb/aadr0604.htm#a1 (accessed Sep 2009).
  • 8. Frempong W, Kiuru A, Ericsson J, Farah M. Cimicifuga racemosa L. Nutt. (black cohosh) and anaphylactic reactions, including face and oral oedema. Uppsala, Sweden: Uppsala Monitoring Centre. http://www.who-umc.org/graphics/6998.pdf (accessed Sep 2009).
  • 9. Ingraffea A, Donohue K, Wilkel C, Falanga V. Cutaneous vasculitis in two patients taking an herbal supplement containing black cohosh. J Am Acad Dermatol 2007; 56 (5 Suppl): S124-S126.
  • 10. Minciullo PL, Saija A, Patafi M, et al. Muscle damage induced by black cohosh (Cimicifuga racemosa). Phytomedicine 2006; 13: 115-118.
  • 11. Pepping J. Black cohosh: Cimicifuga racemosa. Am J Health Syst Pharm 1999; 56: 1400-1402.
  • 12. Mills S, Bone K. Principles and practice of phytotherapy: modern herbal medicine. Edinburgh: Churchill Livingstone, 2000.
  • 13. Nuntanakorn P, Jiang B, Einbond LS, et al. Polyphenolic constituents of Actaea racemosa. J Nat Prod 2006; 69: 314-318.
  • 14. Powell SL, Gödecke T, Nikolic D, et al. In vitro serotonergic activity of black cohosh and identification of N(omega)-methylserotonin as a potential active constituent. J Agric Food Chem 2008; 56: 11718-11726.
  • 15. Burdette JE, Liu J, Chen SN, et al. Black cohosh acts as a mixed competitive ligand and partial agonist of the serotonin receptor. J Agric Food Chem 2003; 51: 5661-5670.
  • 16. Gödecke T, Nikolic D, Lankin DC, et al. Phytochemistry of cimicifugic acids and associated bases in Cimicifuga racemosa root extracts. Phytochem Anal 2009; 20: 120-133.
  • 17. Tsukamoto S, Aburatani M, Ohta T. Isolation of CYP3A4 inhibitors from the black cohosh (Cimicifuga racemosa). Evid Based Complement Alternat Med 2005; 2: 223-226.
  • 18. Horiuchi J, McDowall LM, Dampney RA. Role of 5-HT(1A) receptors in the lower brainstem on the cardiovascular response to dorsomedial hypothalamus activation. Auton Neurosci 2008; 142: 71-76.
  • 19. Villela DC, da Silva LG Jr, Fontes MA. Activation of 5-HT receptors in the periaqueductal gray attenuates the tachycardia evoked from dorsomedial hypothalamus. Auton Neurosci 2009; 148: 36-43.
  • 20. Noguchi M, Nagai M, Koeda M, et al. Vasoactive effects of cimicifugic acids C and D, and fukinolic acid in cimicifuga rhizome. Biol Pharm Bull 1998; 21: 1163-1168.
  • 21. Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981; 30: 239-245.

Author

remove_circle_outline Delete Author
add_circle_outline Add Author

Comment
Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Responses are now closed for this article.