Marijuana Use Can Double Risk of Takotsubo Cardiomyopathy

Marlene Busko

November 22, 2016

NEW ORLEANS, LA — Active marijuana use was associated with a twofold increased risk of takotsubo syndrome, also called stress cardiomyopathy and characterized by transient left-ventricular apical ballooning, in an observational study from a national sample of hospitalized patients[1].

Similar to other studies, most patients with takotsubo were women who had an acute stressful event. Men with takotsubo were more likely to be active marijuana users.

Moreover, even though takotsubo patients who were active marijuana users were younger (mean age 44 vs 66) and had a more favorable cardiovascular risk profile than nonusers, they were more likely have cardiac arrest (2.4% vs 0.8%, P=0.034) or receive an ICD (2.4% vs 0.6%, P=0.008), Dr Amitoj Singh (St Luke's University Health Network, Bethlehem, PA) told the press before he presented the study in a poster session at the American Heart Association (AHA) 2016 Scientific Sessions.

Clinicians should consider that patients who are active marijuana users who present with symptoms that may mimic an MI may have stress cardiomyopathy, Singh told told heartwire from Medscape. "This doesn't establish causation but shows a strong correlation" between marijuana use and cardiomyopathy, he added, so "further prospective studies are needed."

"It does give me some very appropriate worry that exposure to this agent may not be as benign as some people seem to think," said AHA spokesperson Dr Ann Bolger (University of California, San Francisco). "This may be a signal that for some people or under some conditions, marijuana use may create an increased risk of cardiovascular events," she explained to heartwire .

This is a very interesting relationship, but "it certainly cannot be considered suggestive of a cause-and-effect relationship," she too cautioned.

"The AHA has identified that this paucity of information about the relationship of marijuana use and cardiovascular disease is troublesome," given that more states are voting to legalize marijuana for medicinal or recreational use, said press briefing moderator Dr Mariell Jessup (University of Pennsylvania Heart and Vascular Center, Philadelphia).

Stress Stuns the Heart, Left Atrial Swells, Heart Resembles an Octopus Trap

Takotsubo is a rare disease named after the Japanese word for "octopus trap," since that is what the heart resembles in imaging studies, Singh explained. Patients have an acute onset of left ventricular dysfunction, without significant coronary artery stenosis.

One possible mechanism is that stress may cause the release of catecholamines that stun the myocardium. Moreover, endocannabinoid receptors that are present in the human cardiac muscle may play a role in the pathophysiology of takotsubo.

The researchers aimed to determine whether there was an association between marijuana use and takotsubo and, if so, to identify characteristics and outcomes in patients who were or were not active marijuana users.

The study looked at a cohort from the National Inpatient Sample, 33,343 patients who were admitted to the hospital for takotsubo syndrome from 2003 to 2011; of these, 210 patients were active marijuana users, as indicated by patient history or a positive urine drug screening test.

The marijuana users formed a distinct subgroup of takotsubo patients. A total of 64% of the marijuana users were women and 36% were men, whereas 92% of the nonusers were women and 8% were men.

Compared with patients who did not use marijuana, active users were younger and had a lower prevalence of hypertension (38% vs 62%), type 2 diabetes (2.4% vs 17.6%), and hyperlipidemia (15.7% vs 52.4%; all P<0.001).

However, the active users were also more likely to have psychiatric illness or abuse substances. Specifically, they were more likely to have a history of depression (32.9% vs 14.5%), anxiety disorder (28.4% vs 16.2%), or psychosis (11.9% vs 3.8%), and they were more likely to smoke (73.3% vs 28.6%) or abuse alcohol (13.3% vs 2.8%) or cocaine or amphetamines (11.9% vs 0.3%; all P<0.001).

In multivariable binary regression analysis adjusted for known risk factors for takotsubo, marijuana use was an independent predictor of takotsubo (odds ratio 1.99, 95% CI 1.72–2.32; P<0.0001).].

Patients who used marijuana were less likely to die during hospitalization (0% vs 1%, P=NS) and less likely to have a major adverse cardiac event (23% vs 32%, P=0.008).

However, "what was alarming was that even though these were younger patients with fewer traditional cardiovascular risk factors," the marijuana users were more likely to have a cardiac arrest or need an ICD, which is "food for thought," said Singh.

The researchers acknowledge that this is a preliminary study with several limitations. The data did not indicate whether patients smoked or ingested the drug, the amount and frequency of marijuana use, or the time interval between marijuana use and takotsubo symptoms. The data also did not include any state-by-state information, to shed light on how legalization of marijuana in more states may be affecting its use and possible marijuana-related cardiovascular disease.

"We need to understand more about the potential association between marijuana use and cardiovascular adverse events and continue to investigate the mechanisms that might explain it," said Bolger, in agreement with Singh and Jessup.

In the meantime, "patients who use marijuana recreationally should be aware that its safety is not guaranteed and to respond quickly to symptoms of chest pain, shortness of breath, or palpitations," she concluded.

The authors have no relevant financial relationships.

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