Cocaine, Marijuana Use Linked to Mortality in Young MI Patients

Marijuana and/or cocaine use is associated with worse survival in people who have had a myocardial infarction (MI) at a young age, a new retrospective study suggests.

Among adults age 50 years and younger, those who reported use of cocaine or marijuana just before the MI, or who were positive for use of cocaine or marijuana on toxicology — making up about 10% of this population of young MI patients – were twice as likely to die of cardiovascular (CV) or all causes during a median 11-year follow-up.

The work by Ersilia M. DeFilippis, MD, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, and colleagues was published online May 30 in the Journal of the American College of Cardiology.

Importantly, patients with substance use had "fewer risk factors that we often associate with coronary artery disease — a lower rate of diabetes and hyperlipidemia," senior author Ron Blankstein, MD, also from Brigham and Women's Hospital and Harvard Medical School, pointed out to theheart.org | Medscape Cardiology in an interview.

"Therefore, as cardiologists we have an opportunity to improve their outcomes if we treat them more aggressively and we try to look at all of these other potential reversible risk factors, not just the counseling about these substances."

Joshua D. Lee, MD, from the New York University School of Medicine, New York City, and lead author of an editorial that accompanied the article, suggested to theheart.org | Medscape Cardiology that cannabis use may be a marker of a higher risk population.

"If you have someone using cannabis at age 50 with cardiac disease, they almost certainly have other important risk factors that need delivered interventions [related to] heavy drinking, cigarette smoking, exercise, weight loss, and medication adherence," Lee said.

Physicians may also broach the subject of not smoking incinerated plant and switching to potentially safer formulations, such as edibles or vaporized cannabis, he suggested.

Similarly, DeFilippis and colleagues advise: "When young individuals present with an MI, clinicians should assess for potential substance use. This not only allows their care teams to risk stratify these patients, but it also provides opportunity for patient education and implementation of interventions that may lower these risks."

Cocaine a Known CV Risk Factor, Marijuana Less Understood

Although it is well established that cocaine use is a strong risk factor for MI, a recent meta-analysis suggests that there is insufficient evidence on the association of marijuana use with CV outcomes, the researchers note.

With the increasing legalization of medicinal and recreational marijuana, now in 30 states and 9 states, respectively, plus the District of Columbia, there is "an urgent need to understand the health effects of this substance use," they write.

The researchers analyzed data from the YOUNG-MI registry of 2097 patients aged 50 years and younger who had a type 1 MI and were seen at one of two Boston hospitals from 2000 to 2016.

In Massachusetts, medical marijuana was legalized in 2012 and tax-stamped recreational marijuana is expected to be sold to adults over 21 by July 2018.

The researchers identified cocaine or marijuana use from patient charts, based on self-reports and urine toxicology screens on admission.

The patients had a mean age of 44 years and 19% were female; 73% were white. Of these, 125 patients (6%) used marijuana and 99 patients (4.7%) used cocaine, including 36 patients who used both.

Cocaine use remained relatively stable, but the use of marijuana increased over the study period.

At baseline, compared with nonusers, patients who used marijuana were less likely to have diabetes (10.7% vs 20.4%), hypertension (34.4% vs 47.3%), or hyperlipidemia (48.8% vs 60.8%), but they were more likely to be current smokers (65.6% vs 49.1%), all significant differences.

Also compared with nonusers, patients who used cocaine had similar rates of diabetes and hypertension but significantly lower rates of hyperlipidemia, and again they were much more likely to be smokers.

During follow-up, 18.8% of substance users vs 11.3% of nonusers died; 9.4% and 5.3%, respectively, died of CV causes.

The annual rate of death was highest in the cocaine group, followed by the marijuana group.

Table. Risk for All-Cause or CV Mortality During Follow-up

Group	Patients (n)	Hazard Ratio (95% CI)
Group	Patients (n)	All-Cause Death^a	CV Death^a
Marijuana use	125	2.09 (1.25 - 3.50)	2.13 (1.03 - 4.42)
Cocaine use	99	1.91 (1.11 - 3.29)	2.32 (1.11 - 4.85)
Any abuse	224	1.99 (1.35 - 2.97)	2.22 (1.28 - 3.87)
^aBoth adjusted for age, diabetes, hypertension, peripheral vascular disease, smoking, high-density lipoprotein cholesterol, triglycerides, revascularization, creatinine, medications at discharge, and length of stay; CV death also adjusted for sex; all-cause death also adjusted for triglycerides and revascularization.

"Further research is needed," the researchers conclude, "to clarify the cardiovascular effects of these commonly used substances, identify characteristics of young patients at greatest risk of developing MI during use, and develop evidence-based treatment strategies to improve outcomes in those patients presenting with acute coronary syndromes."

More Cannabis Users, More Research Needed

In their editorial, Lee and coauthors Daniel Schatz, MD, and Judith Hochman, MD, also from New York University, focus primarily on the findings with regard to cannabis because the negative effects of cocaine use are more well established.

The paper by DeFilippis and colleagues, they write, "is a timely reminder of how little we know about cannabis consumption, cardiovascular disease…and cannabis' health effects in general."

While these new data may provide a basis to recommend reducing intake of inhaled marijuana smoke, patients may push back, they point out, saying perhaps they have switched to cannabis lozenges, that their cannabis use reduces stress (which is also arguably harmful), or is safer than opioids or cocaine at least — or they may point to the growing population-wide use.

"Here, we as health care providers are kind of stuck, because now we must pause and consider the vast uncertainty of the science regarding cannabis and health, acknowledge key limitations of the data by DeFilippis et al, reflect that we really have no proven effective treatments for cannabis use disorders when we do identify them, and keep in perspective important real-world priorities," they write. "After all, this same patient likely now has some other behavior change heavy lifts: quit smoking, increase exercise, lose weight, limit alcohol, and adhere to guideline-based medical therapies."

Counseling persistent users to consume cannabis edibles rather than smoking marijuana may provide some harm reduction, they note. "We simply do not know whether this would help, but parallels with continued nicotine replacement therapy or e-cigarette use by former adult smokers are not out of place."

"We encourage increasing collaboration among cardiologists and drug use and addiction experts to further advance our understanding of the potential health consequences of increased cannabis use in the United States," they conclude.

"We're going to have more patients coming in with regular cannabis use," Lee said, "so we need to know how to talk to them about it, what to say about it, and how to help them modify risks appropriately, and we really don't know how to do that."

DeFilippis has disclosed no relevant financial relationships. Blankstein has served on the advisory board of Amgen and has received research support from Amgen, Sanofi, and Gilead Sciences. The disclosures of the other authors are listed with the article. The editorialists have no relevant financial disclosures.

J Am Coll Cardiol. Published May 30, 2018. Abstract, Editorial

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