Comparison of Clinical Characteristics and Outcomes of Patients With Reversible Versus Persistent Methamphetamine-Associated Cardiomyopathy

Increased risk of cardiomyopathy in individuals with methamphetamine related disorders in Taiwan

To explore whether Methamphetamine-related disorders (MRDs) will cause the risk of cardiomyopathy in the future. This study used Taiwan's Longitudinal Generation Tracking Database (LGTD) to conduct a 1:4 paired analysis of sex, age, and inclusion year. 17,071 patients with MRDs and 153 patients with cardiomyopathy were selected; 68,264 patients without MRDs and 274 patients with cardiomyopathy were also selected. This study used SPSS 22 statistical software to conduct Cox regression analysis. Patients with MRDs had a 3.421-folds higher risk of cardiomyopathy than patients without MRDs. Men have a 0.735-fold lower risk of developing cardiomyopathy than women. In terms of age group, aged 50-64 and ≧ 65 have a 1.145- and 1.332-folds higher risk of cardiomyopathy, respectively, compared to those aged 20-49. For each one-point increase in Charlson Comorbidity Index (CCI), the risk of cardiomyopathy rises by 58.3%. Specifically, for three types of Methamphetamines (Methamphetamine and other psychostimulant dependence, Methamphetamine or related acting sympathomimetic abuse, Methamphetamine psychosis), the HR for cardiomyopathy in patients with MRDs was 3.864 (p < 0.001), 2.916 (p < 0.001), and 2.295 (p = 0.016) times higher, respectively, compared to patients without MRDs. The Kaplan-Meier log-rank test was used to calculate the cumulative risk of MRDs, showing a significant difference in the cumulative cardiomyopathy incidence between the MRDs and non-MRDs groups (long-rank test, p < 0.001). MRDs will increase the risk of cardiomyopathy. Women are more susceptible to cardiomyopathy than men, and the risk escalates for individuals aged 50-64 and those 65 years or older, compared to the 20-49-year age group. Additionally, an increase in the CCI correlates with a heightened risk of cardiomyopathy. There are important differences between these groups in terms of duration, frequency, and severity of use, with longer exposure and more frequent use increasing the risk of dependence and psychosis, but individual susceptibility, dose, and use patterns also play key roles.

Methamphetamine-associated heart failure: Clinical characteristics and outcomes in a safety net population

BACKGROUND

Methamphetamine use is increasing and is associated with development of heart failure (HF). However, clinical characteristics and outcomes have not been well-described.

OBJECTIVE

To compare outcomes among individuals with HF with and without methamphetamine use in a safety-net setting.

METHODS

This retrospective matched cohort study included individuals with HF with history of methamphetamine use and age, gender-, and year-matched controls without history of methamphetamine use in a municipal health system from 2001 to 2019. One thousand seven hundred seventy-one individuals with methamphetamine use and HF and 3,542 age, sex, and year-of-HF-diagnosis matched controls with HF without methamphetamine use were included. The primary outcome was all-cause mortality. Secondary outcomes included time to HF hospitalization, 30-day, 90-day, and one-year HF, and all-cause readmissions.

RESULTS

The median age of the cohort was 52.1 years and 22.6 % were female. Black/African American was the most common racial identity (methamphetamine: 49.1 %; no methamphetamine: 33 %). There was no significant difference in mortality between groups (40% vs 36.6 %,HR 1.00,95 % CI 0.91,1.10,p = 1.00). A subset had an index HF hospitalization (n = 1,404, 26.4 %) during the study period, including 637 (35.9 %) with history of methamphetamine use and 767 (21.7 %) without history of methamphetamine use (relative risk 1.66,95 % CI 1.52-1.81,p < 0.0001). Among those who were ever hospitalized for HF, individuals with methamphetamine use had increased risk of HF and all-cause readmission at 30 days (RR 1.92,95 % CI 1.36-2.70,p < 0.001), 90 days (RR 1.69,95 % CI 1.35-2.12,p < 0.001), and one year (RR 1.61,95 % CI 1.36-1.91,p < 0.001).

CONCLUSION

Despite having higher all-cause and HF readmission risk, individuals with methamphetamine-associated HF did not have higher mortality risk.

Characteristics of Patients Hospitalized With Methamphetamine-Associated Heart Failure: A Comparative Study of Enrolled vs Nonenrolled Patients

BACKGROUND

Methamphetamine-associated heart failure (MethHF) carries devastating individual and societal consequences; however, our understanding of this condition is limited.

OBJECTIVE

The objective of this study is to compare the sociodemographic and clinical characteristics of patients hospitalized with MethHF with patients hospitalized with heart failure (HF) not associated with methamphetamine (non-MethHF).

METHODS

This was an analysis of screening data from MethHF patients who screened out of the Biological and Physiological Mechanisms of Symptom Clusters in Heart Failure study and a subset of non-MethHF patients enrolled in the study. Descriptive and comparative statistics were used.

RESULTS

Patients hospitalized with MethHF (n = 99), compared with non-MethHF (n = 87), were significantly younger, more often male, more likely from urban areas, and had higher rates of prior emergency room usage. Patients with MethHF also had more nonischemic etiologies and reduced ejection fraction. Nearly a third of patients with MethHF also had a new diagnosis of HF.

CONCLUSIONS

There are a few notable differences in sociodemographic and clinical characteristics between patients hospitalized with MethHF versus non-MethHF.

Community-Based Outreach for People Living With Methamphetamine-Associated Cardiomyopathy

Methamphetamine-associated cardiomyopathy continues to grow within the United States. Although initiation of guideline-directed medical therapy and cessation of methamphetamine are cornerstones of therapy, many barriers to guideline-directed medical therapy use exist for patients with methamphetamine-associated cardiomyopathy. This paper presents a case series of patients who demonstrated profound clinical and echocardiographic improvement with engagement in a community heart failure program paired with the use of alarmed pill containers to target medication adherence.

Implementing Heart Plus: Design and Early Results of a Novel Comanagement Clinic for Patients With Stimulant-associated Cardiomyopathy

We describe the methodology, design, and early results of a novel multidisciplinary co management clinic model with Addiction Medicine and Cardiology providers using contingency management to engage patients with stimulant-associated cardiomyopathy (SA-CMP). Stimulant use, including methamphetamine and cocaine, is increasing in prevalence nationally and is associated with cardiovascular complications. People with SA-CMP have higher rates of mortality and acute care use (eg, emergency department visits, hospital admissions) and lower rates of outpatient care engagement than individuals with non-SA-CMP. This population also has disproportionately elevated rates of mental health and other medical comorbidities, challenges with social determinants of health, including housing and food insecurity, and representation from communities of color. This multidisciplinary comanagement care delivery model, called Heart Plus, was developed and funded as a quality improvement project. It led to a 5-fold increase in outpatient care engagement with a concomitant 53% decrease in acute care use. All participants reported a decrease in stimulant use. With increased clinical stability, patients were able to better engage with outpatient resources for social determinants of health, such as case management, social work, and housing and food service programs. Patients were also empowered to take control over their health while knowing that health care providers cared about their well-being.

Methamphetamine-associated heart failure: a systematic review of observational studies

OBJECTIVE

To conduct a systematic review of observational studies on methamphetamine-associated heart failure (MethHF) .

METHODS

Six databases were searched for original publications on the topic. Title/abstract and included full-text publications were reviewed in duplicate. Data extraction and critical appraisal for risk of bias were performed in duplicate.

RESULTS

Twenty-one studies are included in the final analysis. Results could not be combined because of heterogeneity in study design, population, comparator, and outcome assessment. Overall risk of bias is moderate due to the presence of confounders, selection bias and poor matching; overall certainty in the evidence is very low. MethHF is increasing in prevalence, affects diverse racial/ethnic/sociodemographic groups with a male predominance; up to 44% have preserved left-ventricular ejection fraction. MethHF is associated with significant morbidity including worse heart failure symptoms compared with non-methamphetamine related heart failure. Female sex, methamphetamine abstinence and guideline-directed heart failure therapy are associated with improved outcomes. Chamber dimensions on echocardiography and fibrosis on biopsy predict the extent of recovery after abstinence.

CONCLUSIONS

The increasing prevalence of MethHF with associated morbidity underscores the urgent need for well designed prospective studies of people who use methamphetamine to accurately assess the epidemiology, clinical features, disease trajectory and outcomes of MethHF. Methamphetamine abstinence is an integral part of MethHF treatment; increased availability of effective non-pharmacological interventions for treatment of methamphetamine addiction is an essential first step. Availability of effective pharmacological treatment for methamphetamine addiction will further support MethHF treatment. Using harm reduction principles in an integrated addiction/HF treatment programme will bolster efforts to stem the increasing tide of MethHF.

Clinical Correlates and Outcomes of Methamphetamine-Associated Cardiovascular Diseases in Hospitalized Patients in California

Background

Methamphetamine misuse affects 27 million people worldwide and is associated with cardiovascular disease (CVD); however, risk factors for CVD among users have not been well studied.

Methods and Results

We studied hospitalized patients in California, captured by the Healthcare Cost and Utilization Project database, between 2005 and 2011. We studied the association between methamphetamine use and CVD (pulmonary hypertension, heart failure, stroke, and myocardial infarction). Among 20 249 026 persons in the Healthcare Cost and Utilization Project, 66 199 used methamphetamines (median follow‐up 4.58 years). Those who used were more likely younger (33 years versus 45 years), male (63.3% versus 44.4%), smoked, misused alcohol, and had depression and anxiety compared with nonusers. Methamphetamine use was associated with the development of heart failure (hazard ratio [HR], 1.53 [95% CI, 1.45–1.62]) and pulmonary hypertension (HR, 1.42 [95% CI, 1.26–1.60]). Among users, male sex (HR, 1.73 [95% CI, 1.37–2.18]) was associated with myocardial infarction. Chronic kidney disease (HR, 2.38 [95% CI, 1.74–3.25]) and hypertension (HR, 2.26 [95% CI, 2.03–2.51]) were strong risk factors for CVD among users. When compared with nonuse, methamphetamine use was associated with a 32% significant increase in CVD, alcohol abuse with a 28% increase, and cocaine use with a 47% increase in CVD.

Conclusions

Methamphetamine use has a similar magnitude of risk of CVD compared with alcohol and cocaine. Prevention and treatment could be focused on those with chronic kidney disease, hypertension, and mental health disorders.

A Comprehensive Approach to Managing Methamphetamine-Associated Cardiomyopathy

Methamphetamines are illicit drugs of the amphetamine-type stimulant class that have been increasing in popularity, availability, and purity in recent decades. As a result, rates of methamphetamine-associated cardiomyopathy (MAC) are rising globally. MAC is associated with high rates of sudden cardiac arrest, late presentation, and poor outcomes. This review discusses the medical management of MAC, including anticipated challenges specific to methamphetamine users. Not only are patients with MAC more likely to present at a younger age and with multisystem disease than patients with cardiomyopathy of other etiologies, but there may also be significant behavioral, psychosocial, financial, and system-based challenges to providing the best medical care. An individualized treatment plan that emphasizes methamphetamine abstinence as the foundation of therapy, as well as introducing optimal heart failure therapy and providing multidisciplinary support is likely to result in optimal outcomes. Given the potential reversibility of MAC, institution of guideline-directed heart failure therapy and patient support for adherence to therapy and abstinence from methamphetamines should be energetically pursued.

Characteristics of Methamphetamine-associated Cardiomyopathy and the Impact of Methamphetamine Use on Cardiac Dysfunction

Methamphetamine-associated cardiomyopathy (MACM) in an increasingly prevalent disease yet presenting clinical characteristics have not been well studied. We studied consecutive patients with MACM presenting between June 2018 and March 2020 who were interviewed for drug use and medical history. We retrospectively identified an age- and gender-matched cohort of Non-MACM (NMACM) patients and compared clinical characteristics. 140 patients (70 MACM and 70 NMACM) were studied. MACM patients were young (49.6 ± 10 years) and predominantly male (94%). Compared to NMACM, MACM patients were more likely to be Caucasian (21% vs 6%, p = 0.007) and homeless (47% vs 7%, p = 0.001). MACM was characterized by lower left ventricular ejection fraction (EF) (p <0.001) and greater LV end diastolic volume (LVEDV) (p = 0.024). Right ventricular (RV) dilation was present more often (p = s0.001) and was more often severe (p = 0.03). Among MACM cases, half of the cohort developed MACM within 5 years of starting MA (18% within 1 year). There was no apparent relationship between frequency or amount of MA used weekly with time until heart failure onset. Drug use patterns were not clearly related to the degree of LV structural change however there were more consistent, significant associations with RV and right atrial (RA) size parameters. In conclusion, patients with MACM have more severe myocardial impairment with lower EF, greater LVEDV and RV dilation. Drug use patterns do not clearly impact degree of LV structural changes by echocardiography however may be related to RV and RA size.

Intoxicated Donors and Heart Transplant Outcomes: Long-Term Safety

Supplemental Digital Content is available in the text.

Background:

The opioid crisis has led to an increase in available donor hearts, although questions remain about the long-term outcomes associated with the use of these organs. Prior studies have relied on historical information without examining the toxicology results at the time of organ offer. The objectives of this study were to examine the long-term survival of heart transplants in the recent era, stratified by results of toxicological testing at the time of organ offer as well as comparing the toxicology at the time of donation with variables based on reported history.

Methods:

The United Network for Organ Sharing database was requested as well as the donor toxicology field. Between 2007 and 2017, 23 748 adult heart transplants were performed. United Network for Organ Sharing historical variables formed a United Network for Organ Sharing Toxicology Score and the measured toxicology results formed a Measured Toxicology Score. Survival was examined by the United Network for Organ Sharing Toxicology Score and Measured Toxicology Score, as well as Cox proportional hazards models incorporating a variety of risk factors.

Results:

The number and percent of donors with drug use has significantly increased over the study period (P<0.0001). Cox proportional hazards modeling of survival including toxicological and historical data did not demonstrate differences in post-transplant mortality. Combinations of drugs identified by toxicology were not associated with differences in survival. Lower donor age and ischemic time were significantly positively associated with survival (P<0.0001).

Conclusions:

Among donors accepted for transplantation, neither history nor toxicological evidence of drug use was associated with significant differences in survival. Increasing use of such donors may help alleviate the chronic donor shortage.

Socioeconomic Burden of Rising Methamphetamine-Associated Heart Failure Hospitalizations in California From 2008 to 2018

BACKGROUND

Methamphetamine-associated cardiomyopathy/heart failure (MethHF) is an increasingly recognized disease entity in the context of a rising methamphetamine (meth) epidemic that most severely impacts the western United States. Using heart failure (HF) hospitalization data from the Office of Statewide Health Planning and Development, this study aimed to assess trend and disease burden of MethHF in California.

METHODS

Adult patients (≥18 years old) with HF as primary hospitalization diagnosis between 2008 and 2018 were included in this study. The association with Meth (MethHF) and those without (non-MethHF) were determined by meth-related International Classification of Diseases-based secondary diagnoses. Statistical significance of trends in age-adjusted rates of hospitalization per 100 000 adults were evaluated using nonparametric analysis.

RESULTS

Between 2008 and 2018, 1 033 076 HF hospitalizations were identified: 42 565 were MethHF (4.12%) and 990 511 (95.88%) were non-MethHF. Age-adjusted MethHF hospitalizations per 100 000 increased by 585% from 4.1 in 2008 to 28.1 in 2018, while non-MethHF hospitalizations decreased by 6.0% from 342.3 in 2008 to 321.6 in 2018. The rate of MethHF hospitalization increase more than doubled that of a negative control group with urinary tract infection and meth-related secondary diagnoses (7.82-fold versus 3.48-fold, P<0.001). Annual inflation-adjusted hospitalization charges because of MethHF increased by 840% from $41.5 million in 2008 to $390.2 million in 2018, as compared with an 82% increase for all HF hospitalization from $3.503 billion to $6.376 billion. Patients with MethHF were significantly younger (49.64±10.06 versus 72.20±14.97 years old, P<0.001), predominantly male (79.1% versus 52.4%, P<0.001), with lower Charlson Comorbidity Index, yet they had longer length of stay, more hospitalizations per patient, and more procedures performed during their stays.

CONCLUSIONS

MethHF hospitalizations increased sharply during the study period and contributed significantly to the HF hospitalization burden in California. This emerging HF phenotype, which engenders considerable financial and societal costs, calls for an urgent and concerted public health response to contain its spread.

Characteristics, trends, outcomes, and costs of stimulant-related acute heart failure hospitalizations in the United States

BACKGROUND

Heart failure (HF) hospitalizations remains a significant burden on the health care system. Stimulants including cocaine, amphetamine and its derivatives are amongst the most used illegal substances in the United States. The information regarding stimulant-related HF hospitalizations is scarce. We sought to evaluate the characteristics and trends of stimulant-related HF hospitalizations in the United States and their associated outcomes and resource utilization.

METHODS

Using the National Inpatient Sample (NIS), we identified patients with a primary diagnosis of HF hospitalization. These hospitalizations were further divided into those with and without a concomitant diagnosis of stimulant (cocaine or amphetamine) dependence or abuse. Survey specific techniques were employed to compare trends in baseline characteristics, complications, procedures, outcomes and resource utilization between the two cohorts.

RESULTS

We identified 9,932,753 hospitalizations (weighted) with a primary diagnosis of heart failure, of those 138,438 (1.39%) had a diagnosis of active stimulant use. The proportion of stimulant-related HF hospitalization is on the rise (1.1% to 1.9%). Stimulant-related HF hospitalization was highest amongst age group 30-39 years and 7.9% of HF hospitalizations in this age group were due to stimulant use. The proportion of stimulant-related HF hospitalization for the White and Hispanic race has doubled from 2008 to 2017. Stimulant-related HF hospitalization is associated with increased incidence of in-hospital complications like cardiogenic shock, acute kidney injury and ventricular tachycardia. These patients have more than 7-fold higher discharge against medical advice.

CONCLUSIONS

Stimulant-related HF hospitalizations have been increasing. It is associate with significant morbidity burden and health care utilization.