Myocardial infarction during marijuana smoking in a young female

Pharmacology and adverse effects of new psychoactive substances: synthetic cannabinoid receptor agonists

Over the last decade, new psychoactive substances (NPS) have continuously been the focus of the international society since their emergence on the illicit drug market. NPS can be classified into six groups including; synthetic cannabinoid receptor agonists (SCRAs), stimulants, opioids, dissociatives, sedatives/hypnotics, and classic hallucinogens with psychoactive effects. These are sold as "herbal incense," "bath salts," "legal highs," and "research chemicals". They can be synthesized easily with slight changes in the chemical moieties of known psychoactive substances. NPS are sold worldwide via on- and off-line markets without proper scientific evaluation regarding their safety or harmfulness. Abuse of NPS poses a serious public health issue, and systematic studies on their adverse effects are lacking. Therefore, it would be meaningful to collect currently available data in order to understand NPS and to establish viable solutions to cope with the various health issues related to them. In this article, we reviewed the general pharmacological characteristics, recent findings, and adverse effects of representative NPS; SCRAs. SCRAs are known as the most commonly abused NPS. Most SCRAs, cannabinoid receptor 1 and cannabinoid receptor 2 agonists, are often associated with severe toxicities, including cardiotoxicity, immunotoxicity, and even death, unlike natural cannabinoid Δ⁹-Tetrahydrocannabinol.

Mechanisms for the Risk of Acute Coronary Syndrome and Arrhythmia Associated With Phytogenic and Synthetic Cannabinoid Use

Phytogenic cannabinoids from Cannabis sativa and synthetic cannabinoids are commonly used substances for their recreational and medicinal properties. There are increasing reports of cardiotoxicity in close temporal association with cannabinoid use in patients with structurally normal hearts and absence of coronary arterial disease. Associated adverse events include myocardial ischemia, conduction abnormalities, arrhythmias, and sudden death. This review details the effects of phytogenic and synthetic cannabinoids on diverse receptors based on evidence from in vitro, human, and animal studies to establish a molecular basis for these deleterious clinical effects. The synergism between endocannabinoid dysregulation, cannabinoid receptor, and noncannabinoid receptor binding, and impact on cellular ion flux and coronary microvascular circulation is delineated. Pharmacogenetic factors placing certain patients at higher risk for cardiotoxicity are also correlated with the diverse effects of cannabinoids.

Emergency department presentations related to acute toxicity following recreational use of cannabis products in Switzerland

BACKGROUND

Concomitant use of cannabis and other psychoactive substances is common and it is often difficult to differentiate its acute effects from those of other substances. This study aimed to characterize the acute toxicity of cannabis with and without co-use of other substances.

METHODS

Retrospective analysis of cases presenting at the emergency departments of three large hospitals in Switzerland due to acute toxicity related to cannabis recreational use.

RESULTS

Among 717 attendances related to acute cannabis toxicity, 186 (26 %) were due to use of cannabis alone. The median patient age was 26 years (range 14-68), and 73 % were male. Commonly reported symptoms/signs in lone-cannabis cases included nausea/vomiting (26 %), palpitations (25 %), anxiety (23 %), and chest pain (15 %); there were no fatalities and most intoxications were of minor severity (61 %). Most patients (83 %) using cannabis alone were discharged from the emergency department, 8 % were referred to psychiatric, and two (1 %) to the intensive care; severe complications included psychosis (7 %), coma (6 %), and seizures (5 %) and one patient (<1 %) required intubation. Lone-cannabis patients presented more often with palpitations, anxiety, panic attacks, and chest pain than patients in the co-use group, whereas the latter presented more often with impaired consciousness, agitation, respiratory depression and hallucinations, and were more often admitted to psychiatric or intensive care.

CONCLUSION

Intoxication with cannabis alone was mostly associated with minor toxicity. Nevertheless, severe complications and cases requiring admission to intensive or psychiatric care were also reported, which indicates that intoxication with cannabis alone does not exclude considerable health risks.

Marijuana use and acute myocardial infarction: A systematic review of published cases in the literature

BACKGROUND AND OBJECTIVE

Marijuana use has gained popularity following legalization in the US. Marijuana can affect the heart through various mechanisms. This study aims to conduct a systematic review of published case reports of individuals with acute myocardial infarction (AMI) following marijuana use.

METHODS

We conducted a systematic review of literature, including case reports, case series, and the letter to the editor on MEDLINE. Forty-six studies were included, with a total number of 62 patients with AMI and marijuana use.

RESULTS

The mean age was 27.7 (±10.3) years with male predominance. About 3.7 g marijuana was used for an average of 9.7 years by the patients. From the cases reporting the onset of AMI symptoms, the average time was within 5 h after last marijuana use. The angiographic findings were normal in 36.8% of cases. In 42.1% of individuals, the left anterior descending coronary artery was occluded, making it the most common artery involved, followed by the right coronary artery (10.5%). Most cases were managed medically, followed by thrombectomy and stent placement, and percutaneous transluminal coronary angioplasty (PTCA). Complications included cardio-embolic stroke, and seven deaths were reported.

CONCLUSION

It is important to consider episodic marijuana use as a significant risk factor of AMI, particularly in individuals with no cardiac risk factors, as delay in management can result in fatal outcomes including increased risk of mortality.

Examining the relationship between medical cannabis laws and cardiovascular deaths in the US

BACKGROUND

Several countries and many U.S. states have allowed, for cannabis to be used as therapy to treat chronic conditions or pain., This has increased the use of cannabis, particularly among older people.Because cannabis has been linked to adverse cardiac events in the medical literature, there may be unintended consequences on increased use among older people.

METHODS

We analyze cardiac-related mortality data from the U.S. National Vital Statistics System for 1990-2014. We use difference-in-difference fixed-effects models to assess whether there are increased rates of cardiac-related mortality following passage of medical cannabis programs. We also analyze whether states with more liberal rules on dispensing cannabis show higher mortality rates.

RESULTS

For men, there is a statistically significant 2.3% increase in the rate of cardiac death following passage. For women, there is a 1.3% increase that is also statistically significant. he effects increase or both men and women with age. The effects are also stronger in states with more a lax approach to cannabis dispensing.

CONCLUSION

Policymakers should be aware of a potential unintended consequence of allowing broader use of cannabis, specifically for those more at risk of cardiovascular events.

Cumulative Lifetime Marijuana Use and Incident Cardiovascular Disease in Middle Age: The Coronary Artery Risk Development in Young Adults (CARDIA) Study

OBJECTIVES

To investigate the effects of marijuana in the development of incident cardiovascular and cerebrovascular outcomes.

METHODS

Participants were 5113 adults aged 18 to 30 years at baseline (1985-1986) from the Coronary Artery Risk Development in Young Adults study, who were followed for more than 25 years. We estimated cumulative lifetime exposure to marijuana using repeated assessments collected at examinations every 2 to 5 years. The primary outcome was incident cardiovascular disease (CVD) through 2013.

RESULTS

A total of 84% (n = 4286) reported a history of marijuana use. During a median 26.9 years (131 990 person-years), we identified 215 CVD events, including 62 strokes or transient ischemic attacks, 104 cases of coronary heart disease, and 50 CVD deaths. Compared with no marijuana use, cumulative lifetime and recent marijuana use showed no association with incident CVD, stroke or transient ischemic attacks, coronary heart disease, or CVD mortality. Marijuana use was not associated with CVD when stratified by age, gender, race, or family history of CVD.

CONCLUSIONS

Neither cumulative lifetime nor recent use of marijuana is associated with the incidence of CVD in middle age.

Coronary thrombosis and marijuana smoking: a case report and narrative review of the literature

We encountered evidence of myocardial infarction due to coronary thrombosis in an autopsy of an occasional marijuana smoker. These findings prompted us to perform a narrative review of the literature to determine when post-mortem toxicological tests may support a temporal relationship between marijuana smoking and cardiovascular disease. Toxicological examination showed the presence of Δ-9-tetrahydrocannabinol, its main metabolite and cannabinol in blood and urine. Quali-quantitative analysis revealed that Δ-9-tetrahydrocannabinol was taken within 2 h of the onset of cardiovascular symptoms, according to circumstantial data. Post-mortem toxicological results must take into account the degradation and post-mortem redistribution of analytes. However, for any inference about the specific cardiovascular triggering effect of Δ-9-tetrahydrocannabinol intake, we maintain that cannabinoid analysis in blood samples must be considered an essential requirement to estimate the time of last intake and avoid incomplete documentation. The literature, combined with the present case report, highlights an association between marijuana use and negative cardiovascular events, although few authors have supported their conclusions with toxicological results. Thus, additional research is needed.

Cannabis and cardiotoxicity

Cannabis is the most commonly consumed illicit drug. It is estimated that 4% of the global population between the ages of 15 and 64 smoked marijuana in 2003. Despite the drug's extreme popularity, reports of cannabis-related stroke and myocardial infarction are so rare as to still be reportable. Cannabinoids, the active compounds contained in marijuana, interact with cardiovascular centers in the brain, but also exert direct effects on vascular tone. Recent animal and in vitro studies have yielded conflicting results, some suggesting minimal effect, others suggesting that cannabinoids may be potent myocardial depressants. The observation that cardiotoxicity has never been reported in cancer patients taking dronabinol, the synthetic form of THC, tends to suggest that animal studies may have overstated the cardiovascular risk, which is probably comparable to that of smoking cigarettes.

Cannabis-associated myocardial infarction in a young man with normal coronary arteries

BACKGROUND

The use of cannabis is not usually regarded as a risk factor for acute coronary syndrome. However, several cases of myocardial infarction (MI) associated with cannabis use have been reported in the scientific literature. The etiology of this phenomenon is not known.

OBJECTIVES

To present a case of cannabis-associated MI in which atherosclerotic coronary disease was excluded as a potential etiology by intravascular ultrasound examination, and briefly review the other possible mechanisms by which this effect may be mediated.

CASE REPORT

We present the case of a previously healthy 21-year-old man who regularly smoked cannabis and presented to the Emergency Department with ST-elevation myocardial infarction after participating in a sport. He was also a cigarette smoker, but had no other conventional cardiovascular risk factors. At coronary angiography, a large amount of thrombus was found in the left anterior descending coronary artery. He recovered with medical treatment, and subsequent intravascular ultrasound examination showed no evidence of atherosclerosis at the site of the thrombus.

CONCLUSION

Cannabis-associated MI is increasingly recognized. The etiology is unclear, but we believe this is the first report of the phenomenon where atherosclerotic plaque rupture has been excluded as the cause with a high degree of confidence.

Acute inferior myocardial infarction due to cannabis smoking in a young man

Cannabis smoking, which has euphoric effects, is consistently increasing in Europe. Smoking cannabis is a rare trigger of acute myocardial infarction (MI) by inducing coronary artery spasm. Some cases who have thrombus formation in acute coronary artery and no serious atherosclerotic lesions have been reported in the literature. These cases had involved the left coronary artery. Although some cases were reported with MI after cannabis smoking, only two case reports with inferior MI after cannabis smoking were reported in the literature. The present report is of a young male patient who was affected by acute inferior MI half an hour after cannabis smoking.

Frequency and irregularity of heart rate in drivers suspected of driving under the influence of cannabis

BACKGROUND

Delta 9-tetrahydrocannabinol (THC) is the major active component of cannabis. Cardiovascular effects of THC have previously been reported: tachycardia after intake, but also bradycardia at higher doses. The purpose of this study was, firstly, to investigate the frequency and irregularity of heart rate in a group of cannabis users in their natural surroundings. We also compared THC-positive drivers with a regular pulse with THC-positive drivers with an irregular pulse.

METHODS

The division of Forensic Toxicology and Drug Abuse (DFTDA) at the Norwegian Institute of Public Heath analyzes blood samples from all drivers suspected of driving under the influence of drugs. We studied pulse rate and regularity in 502 THC-positive drivers who tested negative for other substances. As a control group, we randomly selected 125 drug-negative cases from the database of the DFTDA; no alcohol, narcotics, or medicinal drugs of abuse were detected.

RESULTS

The Delta9-THC-positive drivers had a higher mean pulse rate than the control group [82.8 beats/min (SD 16.3) versus 75.6 beats/min (SD 9.2)] and more cases with tachycardia were detected in the Delta9-THC-positive group (19.4% versus 1.6%). There was only one driver with an irregular heart beat in the control group, while there were nine among the Delta9-THC-positive drivers. The drivers with an irregular pulse were over-represented amongst those with the lowest blood Delta9-THC concentrations.

CONCLUSION

This report represents a large study of subjects in a real-life situation and includes observations on pulse frequency, regularity, and blood Delta9-THC concentration. A substantial fraction of Delta9-THC-positive drivers had tachycardia, but there was no correlation between blood Delta9-THC concentration and pulse rate in the present study. We had no further diagnostic information on the cause of the pulse irregularities, but our results indicate that occasional users of cannabis tend to have irregular heart rates at low THC concentrations and at low pulse rates.

An exploratory prospective study of marijuana use and mortality following acute myocardial infarction

BACKGROUND

The relationship of marijuana use with coronary heart disease, including prognosis among patients with coronary heart disease, is uncertain.

METHODS

We conducted an inception cohort study of 1913 adults hospitalized with myocardial infarction at 45 US hospitals between 1989 and 1994, with a median follow-up of 3.8 years. We ascertained total mortality according to self-reported marijuana use in the preceding year.

RESULTS

A total of 52 patients reported marijuana use during the prior year, and 317 patients died during follow-up. Compared with nonuse, marijuana use less than weekly was associated with a hazard ratio of 2.5 (95% CI, 0.9-7.3). The corresponding hazard ratio for weekly use or more was 4.2 (95% CI, 1.2-14.3). The age- and sex-adjusted hazard ratios associated with any use were 1.9 (95% CI, 0.6-6.3) for cardiovascular mortality and 4.9 (95% CI, 1.6-14.7) for noncardiovascular mortality. In a comparison of 42 marijuana users and 42 other patients matched on propensity scores, there were 6 deaths among marijuana users and one among non-users (log-rank P = .06).

CONCLUSIONS

These preliminary results suggest possible hazards of marijuana for patients who survive acute myocardial infarction. Although marijuana use has not been associated with mortality in other populations, it may pose particular risk for susceptible individuals with coronary heart disease.

Cannabis-induced coronary artery thrombosis and acute anterior myocardial infarction in a young man

Information concerning acute myocardial infarction after cannabis usage is limited and the actual mechanism of cannabis-induced myocardial infarction is not well known. In the report, we described a young man with an acute myocardial infarction and cannabis-induced coronary thrombosis.

Marijuana as a trigger of cardiovascular events: speculation or scientific certainty?

Marijuana is the most widely used illicit substance in the United States. Cardiovascular complications in association with marijuana use have been reported during the past three decades. In view of the elevated public interest in this drug's role in pharmacotherapy in the recent years and the aging population of long-term marijuana users from the late 1960s, encounters with marijuana-related cardiovascular adversities may be silently on the rise. The purpose of this article is to increase awareness of the potential of marijuana to lead to cardiovascular disease. Here, we will discuss the physiologic effects of marijuana and include a comprehensive review of the studies and case reports that provide supportive evidence for marijuana as a trigger of adverse cardiovascular events, including tachyarrhythmias, acute coronary syndrome, vascular complications, and even congenital heart defects.

Keep off the grass: marijuana use and acute cardiovascular events

Marijuana is one of the most widely used recreational substances in the world, considered by many consumers as a relatively safe drug with few significant side-effects. We report the case of a 21-year-old man who suffered an acute myocardial infarction following the use of marijuana, despite having no other identifiable risk factors for an acute cardiovascular event. We review the published medical literature regarding acute cardiovascular events following marijuana use and postulate a possible mechanism for this unusual pathological consequence of marijuana use.

Coronary no-flow and ventricular tachycardia associated with habitual marijuana use

A 34-year-old man reported heart fluttering and near syncope a few hours after marijuana smoking. In the emergency department, he was found to have a right bundle-branch-type ventricular tachycardia. The patient underwent a successful electric cardioversion. Coronary angiography showed no pericardial artery stenosis yet very slow coronary blood flow. Clinical tachycardia was also inducible in the electrophysiologic laboratory. After verapamil therapy and cessation of marijuana, his coronary flow normalized and ventricular tachycardia was no longer inducible in the electrophysiologic laboratory. Marijuana use might affect coronary microcirculation and cause ventricular tachycardia. Verapamil therapy and cessation of smoking might be curative.

Cardiovascular consequences of marijuana use

This review describes what is known about effects of marijuana and cannabinoids in relation to human physiological and disease outcomes. The acute physiological effects of marijuana include a substantial dose-dependent increase in heart rate, generally associated with a mild increase in blood pressure. Orthostatic hypotension may occur acutely as a result of decreased vascular resistance. Smoking marijuana decreases exercise test duration in maximal exercise tests, increases the heart rate at submaximal levels of exercise. Tolerance develops to the acute effects of marijuana smoking and delta9-tetrahydrocannibol (THC) over several days to a few weeks. The cardiovascular responses that occur in response to THC are mediated by the autonomic nervous system, with recent findings also demonstrating that the human cannabinoid receptor system plays a role in regulating the cardiovascular response. Although several mechanisms exist by which marijuana use might contribute to the development of chronic cardiovascular conditions or acutely trigger cardiovascular events, there are few data regarding marijuana/THC use and cardiovascular disease outcomes. A large cohort study showed no association of marijuana use with cardiovascular disease hospitalization or mortality. However, acute effects of marijuana use include a decrease of the time until the onset of chest pain in patients with angina pectoris; one study has shown that marijuana may trigger the onset of myocardial infarction. Patients who have coronary heart disease or are at high risk for the development of CHD should be cautioned about the potential hazards of marijuana use as a precipitant for clinical events. Research directions might include more studies of cardiovascular disease outcomes and relationships of marijuana with cardiovascular risk factors, studies of metabolic and physiologic effects of chronic marijuana use that may affect cardiovascular disease risk, increased understanding of the role of the cannabinoid receptor system in cardiovascular regulation, and studies to determine if there is a therapeutic role for cannabinoids in blood pressure control or for neuroprotection after stroke.

Acute cardiovascular fatalities following cannabis use

We report six cases of possible acute cardiovascular death in young adults, where very recent cannabis ingestion was documented by the presence of tetrahydrocannabinol (THC) in postmortem blood samples. A broad toxicological blood analysis could not reveal other drugs. Similar cases have been reported in the literature, but the toxicological analysis has been absent or limited to urine samples, which represent a much broader time window for cannabis intake. This paper presents six case reports, where cannabis alone was detected in blood. Further, an overview over previously published cases, clinical trials and possible patho-physiological mechanisms are presented.

Triggering myocardial infarction by marijuana

BACKGROUND

Marijuana use in the age group prone to coronary artery disease is higher than it was in the past. Smoking marijuana is known to have hemodynamic consequences, including a dose-dependent increase in heart rate, supine hypertension, and postural hypotension; however, whether it can trigger the onset of myocardial infarction is unknown.

METHODS AND RESULTS

In the Determinants of Myocardial Infarction Onset Study, we interviewed 3882 patients (1258 women) with acute myocardial infarction an average of 4 days after infarction onset. We used the case-crossover study design to compare the reported use of marijuana in the hour preceding symptoms of myocardial infarction onset to its expected frequency using self-matched control data. Of the 3882 patients, 124 (3.2%) reported smoking marijuana in the prior year, 37 within 24 hours and 9 within 1 hour of myocardial infarction symptoms. Compared with nonusers, marijuana users were more likely to be men (94% versus 67%, P<0.001), current cigarette smokers (68% versus 32%, P<0.001), and obese (43% versus 32%, P=0.008). They were less likely to have a history of angina (12% versus 25%, P<0.001) or hypertension (30% versus 44%, P=0.002). The risk of myocardial infarction onset was elevated 4.8 times over baseline (95% confidence interval, 2.4 to 9.5) in the 60 minutes after marijuana use. The elevated risk rapidly decreased thereafter.

CONCLUSIONS

Smoking marijuana is a rare trigger of acute myocardial infarction. Understanding the mechanism through which marijuana causes infarction may provide insight into the triggering of myocardial infarction by this and other, more common stressors.

Myocardial infarction in young patients

Myocardial infarction in persons under the age of 45 years accounts for 6% to 10% of all myocardial infarctions in the United States. In this age group, it is predominantly a disease of men. Important risk factors include a family history of myocardial infarction before age 55 years, hyperlipidemia, smoking, and obesity. Unlike older patients, approximately half of young patients have single-vessel coronary disease, and in up to 20%, the cause is not related to atherosclerosis. Coronary angiography may be warranted in young patients with myocardial infarction to define the anatomy of the disease and to permit optimal management.

Acute myocardial infarction in juvenile patients with normal coronary arteries

Three patients below 21 years of age presented with typical symptoms, electrocardiographic pattern, and levels of enzymes suggestive for acute myocardial infarction. Various risk factors for coronary artery disease were present in all three patients. Coronary angiography showed normal coronary arteries in all. Thus, acute myocardial infarction may be experienced even in very young patients. Clinical and angiographic findings are discussed on the basis of the existing reports in the literature.