Wet cupping (WC) is a traditional therapy of skin suction-assisted bloodletting that is widely used in modern alternative medicine in Asia and the Middle East. Herein, we report the case of a male who presented with ST-elevation myocardial infarction (STEMI) and life-threatening anemia and underwent excessive WC.

A 55-year-old male presented with chest pain (30 min) and dyspnea (3 wk). His initial electrocardiogram suggested STEMI in the anterior wall. Furthermore, his laboratory results showed severe anemia with a hemoglobin level of 4.1 g/dL. Of note, the patient underwent regular WC therapy for chronic back pain, which he had recently intensified. His WC practice resulted in life-threatening anemia and eventually STEMI. Percutaneous coronary intervention in the left anterior descending artery was performed to treat the STEMI. His dyspnea dramatically improved after the transfusion, and his hemoglobin level returned to 14.8 g/dL within 2 mo after discharge. He has been uneventful for the last seven years of follow-up.

The current case demonstrates that excessive WC without adequate medical monitoring can result in severe anemia, which can further develop into STEMI.

Wet cupping (WC) is one of the most widely used traditional therapies for musculoskeletal pain or headache that is performed in the Middle East, Asia, and Europe[1]. WC promotes bloodletting by applying subatmospheric pressure to a glass cup attached to a skin-pricked, bleeding lesion[1]. Herein, we report a man who self-performed excessive WC and presented with ST-elevation myocardial infarction (STEMI) and life-threatening anemia.

The final diagnosis of the presented case was anemia due to excessive WC. The patient also developed STEMI, which was possibly induced by vigorous heart contractions compensating for the poor blood supply caused by life-threatening anemia.

A transfusion was immediately initiated, while concurrent iron supplementation was performed after consultation with hematology. Four packed red blood cells were transfused. After transfusion, the patient’s dyspnea was dramatically ameliorated and his hypotension recovered to normal blood pressure (120/80 mmHg). His Hb was 7.9 g/dL when he was discharged 2 d post-PCI. We also educated the patient regarding the consequences of unmonitored WC. Iron supplementation was maintained for the next 2 mo. Dual-antiplatelet therapy, angiotensin-converting enzyme inhibitors, beta-blockers, and statins were also given.

Two months after PCI, during his outpatient department visit, the patient’s Hb level had increased to 14.8 g/dL and his symptoms were completely alleviated. He no longer performs WC to this day and has been uneventful for the last seven years. A timeline of the patient’s disease course is shown in Table 1.

WC therapy is the application of subatmospheric pressure to a skin-attached glass or plastic cup after pricking precise acupuncture points or painful areas (Figure 1D)[1]. The intensity of bruises and the amount of suctioned blood are dependent on the strength of the negative pressure applied. Such practices were traditionally performed in Asia, the Middle East, and Europe with great popularity because they were thought to remove harmful blood or toxins that were causative of diseases[1]. Even today, WC is widely performed in Asia and the Middle East in the field of alternative medicine for chronic musculoskeletal pain. Although several small, modern studies have investigated the therapeutic efficacy of WC, the benefits remain relatively unknown[2].

The patient in our study practiced regular WC for his chronic upper back pain. He also stated that as his shortness of breath developed, he had more frequently performed WC during the 3 wk prior to admission because he thought that it would improve his symptoms. Considering that his dyspnea may have developed with decreased cardiac output due to blood loss, his intensified bloodletting may have aggravated his heart failure to a further extent. Furthermore, vigorous heart contractility to compensate for the loss of preload may also have facilitated the imbalance between the patient’s myocardial supply and consumption.

Anemia is a well-established risk factor for future adverse events in patients with acute coronary syndrome, stroke, and heart failure[2,3]. Although whether anemia leads to the formation of atherosclerosis is relatively undiscovered, an intravascular ultrasound study revealed that anemia was independently associated with thin-cap fibroatheroma, which is thought to be impending plaque rupture[4]. The mechanism of this finding has not been elucidated; however, it has been demonstrated that hypovolemia-induced hypernatremia leads to chronic inflammation and the development of atherosclerosis[5]. Considering that the patient had relatively low levels of low-density lipoprotein and triglycerides, it is conceivable that other mechanisms, anemia in this case, may have played a major role in the development of atherosclerosis and the rupture of plaque. The dehydrated state of the patient may have promoted systemic inflammation, further leading to the formation of a vulnerable plaque and the subsequent rupture that caused the STEMI[5].

The current case demonstrates that excessive WC without adequate medical monitoring can result in severe anemia, which can further develop into life-threatening myocardial infarction.

We thank Professor Junshik Hong, who works at Seoul National University Hospital, for offering great advice for managing this patient.