ST-elevation Myocardial Infarction and Complete Heart Block in a Nitrate-free Patient using a New Emerging Substance called Rhino.

The pervasive use of counterfeit sexual enhancement supplements is increasing worldwide. There are thousands of vendors on the internet while local gas stations and convenience stores are selling it across the United States (US). We report a case of right coronary artery ST-segment elevation and complete heart block in a nitrate-free patient shortly after consuming three 950 mg pills of a sexual enhancer known as rhino and completing sexual intercourse. Coronary angiography revealed 100% occlusion of the right coronary artery and a drug-eluting stent was inserted with a transvenous pacer that he tolerated well, and recovered without complications. The counterfeit drug has gained traction for its high user satisfaction and low cost among recreational customers. The Food and Drug Administration (FDA), through its MedWatch program, has frequently released citations to consumers warning them against rhino since 2015, while their labs have recognized two prime ingredients: sildenafil and tadalafil. Although adverse cardiac risk with this therapeutic class is low, we aim to parse out its temporal relationship with rhino, an enhancer containing 14-200 times the prescription limits of sildenafil and tadalafil.