Cardiac arrest associated with synthetic cannabinoid use and acquired prolonged QTc interval: A case report and review of literature

Contemporary nationwide trends in major adverse cardiovascular events in young cannabis users without concomitant tobacco, alcohol, cocaine use

BACKGROUND

Cannabis use has increased among young individuals in recent years. Although dependent cannabis use disorder (CUD) has been associated with various cardiac events, its effects on young adults without concurrent substance use remain understudied.

AIM

To examine trends in hospitalizations for major adverse cardiac and cerebrovascular events (MACCE) in this cohort.

METHODS

We used the National Inpatient Sample (2016-2019) to identify hospitalized young individuals (18-44 years), excluding those with concurrent substance usage (tobacco, alcohol, and cocaine). They were divided into CUD+ and CUD-. Using International Classification of Diseases-10 codes, we examined the trends in MACCE hospitalizations, including all-cause mortality (ACM), acute myocardial infarction (AMI), cardiac arrest (CA), and acute ischemic stroke (AIS).

RESULTS

Of 27.4 million hospitalizations among young adults without concurrent substance abuse, 4.2% (1.1 million) had co-existent CUD. In CUD+ group, hospitalization rates for MACCE (1.71% vs 1.35%), AMI (0.86% vs 0.54%), CA (0.27% vs 0.24%), and AIS (0.49% vs 0.35%) were higher than in CUD- group (P < 0.001). However, rate of ACM hospitalizations was lower in CUD+ group (0.30% vs 0.44%). From 2016 to 2019, CUD+ group experienced a relative rise of 5% in MACCE and 20% in AMI hospitalizations, compared to 22% and 36% increases in CUD- group (P < 0.05). The CUD+ group had a 13% relative decrease in ACM hospitalizations, compared to a 10% relative rise in CUD- group (P < 0.05). However, when adjusted for confounders, MACCE odds among CUD+ cohort remain comparable between 2016 and 2019.

CONCLUSION

The CUD+ group had higher rates of MACCE, but the rising trends were more apparent in the CUD- group over time. Interestingly, the CUD+ group had lower ACM rates than the CUD- group.

Potential perioperative cardiovascular outcomes in cannabis/cannabinoid users. A call for caution

Background

Cannabis is one of the most widely used psychoactive substances. Its components act through several pathways, producing a myriad of side effects, of which cardiovascular events are the most life-threatening. However, only a limited number of studies address cannabis's perioperative impact on patients during noncardiac surgery.

Methods

Studies were identified by searching the PubMed, Medline, EMBASE, and Google Scholar databases using relevant keyword combinations pertinent to the topic.

Results

Current evidence shows that cannabis use may cause several cardiovascular events, including abnormalities in cardiac rhythm, myocardial infarction, heart failure, and cerebrovascular events. Additionally, cannabis interacts with anticoagulants and antiplatelet agents, decreasing their efficacy. Finally, the interplay of cannabis with inhalational and intravenous anesthetic agents may lead to adverse perioperative cardiovascular outcomes.

Conclusions

The use of cannabis can trigger cardiovascular events that may depend on factors such as the duration of consumption, the route of administration of the drug, and the dose consumed, which places these patients at risk of drug-drug interactions with anesthetic agents. However, large prospective randomized clinical trials are needed to further elucidate gaps in the body of knowledge regarding which patient population has a greater risk of perioperative complications after cannabis consumption.

The synthetic cannabinoids menace: a review of health risks and toxicity

Synthetic cannabinoids (SCs) are chemically classified as psychoactive substances that target the endocannabinoid system in many body organs. SCs can initiate pathophysiological changes in many tissues which can be severe enough to damage the normal functionality of our body systems. The majority of SCs-related side effects are mediated by activating Cannabinoid Receptor 1 (CB1R) and Cannabinoid Receptor 2 (CB2R). The activation of these receptors can enkindle many downstream signalling pathways, including oxidative stress, inflammation, and apoptosis that ultimately can produce deleterious changes in many organs. Besides activating the cannabinoid receptors, SCs can act on non-cannabinoid targets, such as the orphan G protein receptors GPR55 and GPR18, the Peroxisome Proliferator-activated Receptors (PPARs), and the Transient receptor potential vanilloid 1 (TRPV1), which are broadly expressed in the brain and the heart and their activation mediates many pharmacological effects of SCs. In this review, we shed light on the multisystem complications found in SCs abusers, particularly discussing their neurologic, cardiovascular, renal, and hepatic effects, as well as highlighting the mechanisms that intermediate SCs-related pharmacological and toxicological consequences to provide comprehensive understanding of their short and long-term systemic effects.

New synthetic cannabinoids and the potential for cardiac arrhythmia risk

Synthetic cannabinoid receptor agonists (SCRAs) have been associated with QT interval prolongation. Limited preclinical information on SCRA effects on cardiac electrogenesis results from the rapid emergence of new compounds and restricted research availability. We used two machine-learning-based tools to evaluate seven novel SCRAs' interaction potential with the hERG potassium channel, an important drug antitarget. Five SCRAs were predicted to have the ability to block the hERG channel by both prediction tools; ADB-FUBIATA was predicted to be a strong hERG blocker. ADB-5Br-INACA and ADB-4en-PINACA showed varied predictions. These findings highlight potentially proarrhythmic hERG block by novel SCRAs, necessitating detailed safety evaluations.

Electrocardiographic Markers of Arrhythmogenic Risk in Synthetic Cannabinoids Users

Background: Synthetic cannabinoids (SCs) users appeared to have heightened risk for cardiac arrhythmias; however, current line of research is insufficient in terms of demonstrating both conventional and novel electrocardiographic arrhythmia risk indicators in this population. Objective(s): We aimed to investigate P-wave dispersion (Pwd), corrected QT interval (QTc), QTc dispersion (QTcd), Tpeak-Tend (Tp-e), Tp-e/QT ratio, corrected JT interval (JTc), and JTc dispersion (JTcd), which are shown among the risk factors for emergence of an arrhythmia, among SCs users, suggestive of possible adverse effects of SCs on the cardiac rhythm. Methods: Forty-one male SCs user patients who met Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) substance use disorder criteria and 41 healthy male controls included in the study. Substance-related characteristics were recorded. Electrocardiography recordings under standardized procedure of all participants were performed and arrhythmia risk markers were calculated from electrocardiograms (ECGs). Results: Age and heart rate per minute did not significantly differ between the groups. SCs user group had significantly higher Pwd, QTc, QTcd, Tp-e, Tp-e/QTc ratio, JTc, and JTcd values compared with controls. Among risk markers, only Pwd was significantly correlated with duration of SCs use. Conclusions: Alterations in ECG-derived markers of arrhythmia, which are acquired through an easy and cheap method, should be evaluated for the prediction and prevention of severe cardiac conditions in patients with SCs use.

Synthetic Cannabinoids-Related Cardiovascular Emergencies: A Review of the Literature

Synthetic cannabinoids (SCBs) are a group of psychoactive compounds, known to cause a range of multisystem adverse events, including the cardiovascular system. The aim of this review is to provide an overview of the literature on cardiovascular emergencies associated with SCBs. A systematic search of electronic databases was conducted to identify relevant studies published between January 2010 and September 2022. Inclusion criteria were studies reporting on cardiovascular emergencies in individuals with SCB abuse. The search yielded a total of 43 studies, including case reports, case series, and meta-analyses. This review indicates that SCB abuse can lead to a range of cardiovascular emergencies, including acute coronary syndrome, arrhythmias, and hypertension. The onset of these emergencies is often sudden and may occur in previously healthy individuals. The severity of these complications can vary widely, with some cases resulting in cardiac arrest or death. Management strategies for SCB-related cardiovascular emergencies include supportive care, pharmacological interventions, and, sometimes, invasive procedures. There is no specific antidote against SCB to date. In conclusion, SCB abuse is associated with various cardiovascular emergencies, which can be life-threatening in some cases. Early recognition and management of these emergencies are critical for improving outcomes. Further research is needed to better understand the underlying mechanisms of SCB-related cardiovascular complications and to develop effective prevention and management strategies.

Torsades de Pointes due to Excessive Marijuana Use in a Susceptible Patient

There are several recent reports of tetrahydrocannabinol vaping-related sudden cardiac arrest, and the mechanisms are unclear. We report a unique case of a 19-year-old female who suffered documented prolonged QTc leading to Torsades de pointes and cardiac arrest in the setting of frequent marijuana wax vaping. While she demonstrated normal baseline QTc measurements years earlier, she was found to have a genetic predisposition to QTc prolongation (genetic mutation, family history of prolonged QTc), suggesting that specific patient populations are at higher risk of these adverse events. The patient was acutely managed with isoproterenol to increase the heart rate and was discharged on nadolol after placement of an implantable cardioverter-defibrillator. Marijuana wax vaping and dabbing may cause fatal Torsades de pointes in susceptible patients, and further research is required to identify these patients a priori.

Synthetic Cannabinoids and Cathinones Cardiotoxicity: Facts and Perspectives

New psychoactive substances (NPS) constitute a group of psychotropic substances, designed to mimic the effects of traditional substances like cannabis, cocaine, MDMA, khat, which was not regulated by the 1961 United Nations Convention on Narcotics or the 1971 United Nations Convention on Psychotropic Substances. Illegal laboratories responsible for their production regularly developed new substances and placed them on the market to replace the ones that have been banned; for this reason, during the last decade this class of substances has represented a great challenge for the public health and forensic toxicologists. The spectrum of side effects caused by the intake of these drugs of abuse is very wide since they act on different systems with various mechanisms of action. To date most studies have focused on the neurotoxic effects, very few works focus on cardiotoxicity. Specifically, both synthetic cannabinoids and synthetic cathinones appear to be involved in different cardiac events, including myocardial infarction and sudden cardiac death due to fatal arrhythmias. Synthetic cannabinoids and cathinones cardiotoxicity are mainly mediated through activation of the CB1 receptor present on cardiomyocyte and involved with reactive oxygen species production, ATP depletion and cell death. Concerns with the adrenergic over-stimulation induced by this class of substances and increasing oxidative stress are mainly reported. In this systematic review we aim to summarize the data from all the works analyzing the possible mechanisms through which synthetic cannabinoids and synthetic cathinones damage the myocardial tissue.