GPT and heart failure: Examples of this so-called “2-hit phenomenon” include sudden dramatic increases in serum alanine transaminase activity in combination with severe hemolytic or blood loss anemia, hypoxemia, cardiac failure, hypotensive shock, gastric dilatation volvulus, hypotension during general anesthesia, and administration of cytochrome P450-metabolized xenobiotics (e.g., NSAIDs) that form oxidative adducts or electrophiles29.