Cardiac magnetic resonance in cocaine-induced myocardial damage: cocaine, heart, and magnetic resonance

Cocaine-Induced Cardiac Alterations: Histological and Immunohistochemical Post-Mortem Analysis

Background: Cocaine abuse represents a serious health issue. The cardiovascular system is one of the main sites on which cocaine elicits its toxicity, as indicated by deadly events mainly related to myocardial infarction. The main aim of this study was to characterize the histological and immunohistochemical alterations related to cocaine abuse in cardiac tissue. Methods: Cardiac tissue samples derived from cocaine-related (n = 30) and not-cocaine-related deaths (n = 30). Histomorphology evaluations and immunohistochemistry for inflammatory biomarkers (CD45 and CD3) have been performed on formalin-fixed, paraffin-embedded (FFPE) cardiac tissue samples. Results: A higher frequency of cardiac alterations, such as wavy fibers, interstitial edema, fibrosis and hemorrhagic extravasation, were found in the group of cocaine users compared to the control group. Moreover, immunohistochemical analysis showed higher levels of inflammatory cells infiltrate within the cocaine-related deaths group. Conclusions: These data could shed new light on the complex relationship between cocaine use and cardiac alterations. Specifically, our data support the evidence that cocaine abuse is related to cardiac inflammation. Therefore, the generation of an inflammatory state could promote functional and structural cardiac alterations and lead ultimately to myocardial infarction. This would explain the high frequency of acute myocardial infarction in cocaine users.

Acute Myocarditis and Inflammatory Cardiomyopathies: Insights From Cardiac Magnetic Resonance Findings

Myocardial inflammation encompasses a broad spectrum of conditions, including acute myocarditis, chronic inflammatory cardiomyopathy, and several overlapping entities that differ in clinical presentation, pathophysiology, and progression. These conditions range from self-limiting acute inflammation to chronic myocardial injury and dysfunction. The etiologic classification of myocardial inflammation highlights the complexity of its pathogenesis, involving direct tissue damage, immune-mediated mechanisms, and environmental triggers. Cardiac magnetic resonance (CMR) imaging has become a central diagnostic tool in the assessment of myocardial inflammation, providing precise characterization of myocardial tissue, assessing cardiac function, and stratifying prognosis. Advanced techniques such as T1 and T2 mapping and extracellular volume quantification have further expanded its diagnostic capabilities. This review highlights the essential role of CMR in diagnosing myocardial inflammation, recognizing various imaging findings associated with different underlying causes, and informing clinical management. The standardization of CMR protocols, along with advancements in imaging techniques and strengthened interdisciplinary collaboration, represents a fundamental step toward improving diagnostic accuracy, patient outcomes, and the understanding of the broad spectrum of myocardial inflammatory diseases.

Cardiovascular and pulmonary complications of recreational drugs: A pictorial review

Recreational drug abuse constitutes a serious health problem worldwide. Consumption of cocaine, amphetamine-type stimulants, opioids and cannabis can lead to multiple acute and chronic cardiopulmonary complications, resulting in high morbidity and mortality. These complications may be first detected at imaging, since clinical presentation is usually non-specific. Cardiovascular complications include myocardial infarction, endocarditis, aortic dissection, infectious pseudoaneurysm, retained needle fragments, cardiomyopathy and pulmonary arterial hypertension. Pulmonary complications encompass pulmonary oedema, crack lung, pneumonia, septic emboli, barotrauma, airway disease, emphysema and excipient lung disease. Knowledge of the cardiopulmonary imaging manifestations of illicit drug use in conjunction with clinical history and a high grade of suspicion enable an accurate diagnosis and appropriate management plan. In this article we aim to provide a pictorial review of the most frequent cardiopulmonary manifestations of recreational drugs, emphasizing the underlying pathophysiologic mechanisms and the various imaging appearances.

Characteristic Cardiac Magnetic Resonance (CMR) Imaging Findings of Cocaine-Induced Myocardial Injury

Cocaine is a widely available illicit substance with a costly financial and social burden on the healthcare infrastructure. Both acute and chronic cocaine use can lead to sequelae of cardiac diseases, including myocardial infarction, aortic dissection, and cardiomyopathy. Cardiac magnetic resonance (CMR) imaging is a powerful tool for detecting myocardial injury leading to prompt treatment and risk stratification. We present two differing cases of sequelae of myocardial injury as a result of cocaine use. We present critical findings on CMR imaging, including myocardial injury patterns, which can help differentiate between acute and chronic injury and assess the extent of damage. Cocaine exerts potent sympathomimetic effects, increasing myocardial oxygen demand and causing coronary vasospasm, thrombosis, and direct myocyte toxicity. Acute cocaine use significantly elevates the risk of myocardial infarction, while chronic use can lead to cardiomyopathy and heart failure. CMR features include wall motion abnormalities, myocardial perfusion defects, and fibrosis. Early identification and intervention can potentially reverse interstitial fibrosis before progression to irreversible damage. CMR is an essential diagnostic tool for characterizing myocardial injury, distinguishing between reversible and irreversible damage, and providing prognostic information on cocaine-induced myocardial injury. The cases highlight the importance of CMR in managing and understanding the full spectrum of cocaine-related cardiac damage.

COVID-19 Associated Fulminant Myocarditis in a Fully-Vaccinated Female: A Case Report with Clinical Follow-up

Background

Myocarditis is considered a serious adverse event after COVID-19 infection. The risk and severity of myocarditis after COVID-19 disease decreased significantly in the vaccinated population. We present a case of cardiac magnetic resonance proven fulminant myocarditis following COVID-19 disease in a young female who was previously vaccinated with 2 doses of the BIBP (Sinopharm) vaccine.

Case summary

A 29-year-old female was referred to the hospital with acute chest pain, dyspnea, and nausea. Her electrocardiogram revealed ST-segment elevation in anterolateral leads with reciprocal changes in inferior leads. She was primarily diagnosed with ST-elevation myocardial infarction following spontaneous coronary artery dissection (SCAD) according to her age and gender. Her coronary angiography was normal. RT-PCR nasopharyngeal swab was positive for SARS-COV-2 infection. According to her history and excluding coronary artery diseases, she was clinically diagnosed with myocarditis and received corticosteroids, IVIG, and colchicine. She was discharged in a favorable condition after 11 days of hospitalization. Cardiac magnetic resonance imaging confirmed the diagnosis of myocarditis according to the updated lake Louise criteria. On her 4-month follow-up, she was asymptomatic, and her echocardiography showed improvement in biventricular function.

Discussion

The diagnosis of myocarditis caused by COVID-19 infection may be challenging as the symptoms of myocarditis, and COVID-19 disease may overlap. It should be considered when patients have acute chest pain, palpitation, elevated cardiac biomarkers, and new abnormalities in ECG or echocardiography. Cardiac MRI is a non-invasive gold standard modality for diagnosing and follow-up of myocarditis and should be used in clinically suspected myocarditis. The long-term course of myocarditis following COVID-19 disease is still unclear, but some evidence suggests it may have a favorable mid-term outcome.

Cocaethylene: When Cocaine and Alcohol Are Taken Together

Cocaine is taken frequently together with ethanol and this combination produces a psychoactive metabolite called cocaethylene which has similar properties to the parent drug and may be more cardiotoxic. Cocaethylene has a longer half-life than cocaine, so that people who combine cocaine and ethanol may experience a longer-lasting, as well as more intense, psychoactive effect. Cocaethylene is the only known instance where a new psychoactive substance is formed entirely within the body. Although known to science for decades, cocaethylene has not been extensively studied and even its metabolic pathways are not entirely elucidated. Like its parent drug, cocaethylene blocks the reuptake of dopamine and increases post-synaptic neuronal activity; the parent drug may also block reuptake of serotonin as well. Cocaethylene has been studied in animal models in terms of its pharmacology and its potential neurological effects. Since the combination of cocaine and alcohol is commonly used, it is important for clinicians to be aware of cocaethylene, its role in prolonging or intensifying cocaine intoxication, and how it may exacerbate cocaine-induced cardiovascular disorders. Most cardiac-related risk assessment tools do not ask about cocaine use, which can prevent clinicians from making optimal therapeutic choices. Greater awareness of cocaethylene is needed for clinicians, and those who use cocaine should also be aware of the potential for polysubstance use of cocaine and ethanol to produce a potentially potent and long-lasting psychoactive metabolite.

Oxidative Stress and Cocaine Intoxication as Start Points in the Pathology of Cocaine-Induced Cardiotoxicity

Psychomotor stimulants are the most commonly used prohibited substances after cannabis. Globally, their use reaches epidemiological proportions and is one of the most common causes of death in many countries. The use of illicit drugs has negative effects on the cardiovascular system and is one of the causes of serious cardiovascular pathologies, ranging from abnormal heart rhythms to heart attacks and sudden cardiac death. The reactive oxygen species generation, toxic metabolites formation, and oxidative stress play a significant role in cocaine-induced cardiotoxicity. The aim of the present review is to assess acute and chronic cocaine toxicity by focusing on the published literature regarding oxidative stress levels. Hypothetically, this study can serve as a basis for developing a rapid and effective method for determining oxidative stress levels by monitoring changes in the redox status of patients with cocaine intoxication.

Cocaine induced heart failure: report and literature review

Heart failure is a complex clinical syndrome associated with high mortality and morbidity, creating a major public healthcare problem. It has a variety of etiologies, including substance abuse. Cocaine-induced cardiotoxicity is caused by direct effects of inhibition of sodium channels and indirect effects by inhibiting catecholamine uptake leading to increased sympathetic activity. Management is through the cessation of cocaine use and implantation of guideline-directed medical therapy for heart failure with the exception of beta-blockers as their safe usage is still controversial due to the risk of the unopposed alpha-adrenergic activity. Dexmedetomidine (Precedex) and Benzodiazepines (i.e., midazolam) are options for patients that demonstrate signs and symptoms of acute cocaine intoxication. If the actions of benzodiazepines fail to achieve hemodynamic stability, nitroglycerin may be used (especially in patients with cocaine-associated chest pain and hypertension). Cardiac transplantation is recommended for those who have demonstrated severe cardiovascular disease from cocaine. We present a 43-year-old male with a long-standing history of cocaine use who developed cardiomyopathy and severe acute decompensated heart failure found to have an ejection fraction of <20% admitted to the intensive care unit. He required inotropic support with milrinone and mechanical ventilation. He was later extubated and then discharged with an outpatient evaluation for a cardiac transplant.

Drugs of Abuse and Heart Failure

Substance use is common among those with heart failure (HF) and is associated with worse clinical outcomes. Alcohol, tobacco, cannabis, and cocaine are commonly abused substances that can contribute to the development and worsening of HF. Heavy alcohol consumption can lead to dilated cardiomyopathy, whereas moderate intake may decrease incident HF. Tobacco increases the risk of HF through coronary artery disease and coronary artery disease-independent mechanisms. Continued smoking worsens outcomes for those with HF and cessation is associated with an improved risk of major adverse cardiac events. Cannabis has complex interactions on the cardiovascular system depending on the method of consumption, amount consumed, and content of cannabinoids. Delta-9-tetrahydrocannabinol can increase sympathetic tone, cause vascular dysfunction, and may increase the risk of myocardial infarction. Cannabidiol is cardioprotective in preclinical studies and is a potential therapeutic target. Cocaine increases sympathetic tone and is a potent proarrhythmogenic agent. It increases the risk of myocardial infarction and can also lead to a dilated cardiomyopathy. The use of beta-blockers in those with HF and cocaine use is likely safe and effective. Future studies are needed to further elucidate the impact of these substances both on the development of HF and their effects on those who have HF.

Cocaine and Cardiotoxicity: A Literature Review

Long-term cocaine use, as well as acute cocaine use, is associated with adverse cardiovascular consequences, including arrhythmias, angina, myocardial infarction, heart failure, and other conditions. Over the long term, cocaine can result in structural changes to the heart such as increased left-ventricular mass and decreased left-ventricular end-diastolic volume. Patients arriving with cocaine-associated cardiovascular complaints may not be forthcoming about their cocaine or polysubstance abuse or may be unresponsive. The role of beta-blockers, a first-line treatment for many forms of heart disease, is controversial in this population. Cocaine is a powerful sympathomimetic agent, and it was thought that beta-blockade would result in unopposed alpha-adrenergic stimulation and adverse consequences. A number of small, single-center, retrospective and observational studies suggest that beta-blockers may be safe, effective, and beneficial in this population. Further study is needed to clarify the role of beta-blockers in this population.