A Comprehensive Approach to Managing Methamphetamine-Associated Cardiomyopathy

Michael Osekowski; Adam Trytell; Andre La Gerche; David Prior; Andrew MacIsaac; Elizabeth D. Paratz

Disclosures

Am J Cardiovasc Drugs. 2022;22(4):385-393. 

In This Article

Abstract and Introduction

Abstract

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.

Introduction

Methamphetamines are potent, highly addictive stimulants, the chronic use of which leads to multisystem dysfunction and disease. A major driver of methamphetamine-associated morbidity and mortality is the development of cardiomyopathy.[1] The cardiomyopathy associated with methamphetamine use is generally a dilated phenotype with reduced ejection fraction, although hypertrophic cardiomyopathy, stress-induced cardiomyopathy, and heart failure with preserved ejection fraction have all been described. Despite the known association between methamphetamine use and cardiac dysfunction, the exact pathogenesis of methamphetamine-associated cardiomyopathy (MAC) remains poorly understood. Patients with MAC typically present with more severe disease at a younger age and with greater rates of multisystem involvement than patients with cardiomyopathy of other etiologies.[2] Prompt recognition, assessment, and management of MAC is therefore essential.

Management follows the same guidelines as other causes of heart failure with reduced ejection fraction (HFrEF), requiring prompt initiation of drug therapy to optimize cardiac function and improve symptoms, quality of life, morbidity, and mortality while reducing hospitalizations. The evidence base supporting heart failure medication use specifically in patients with MAC is limited, and recommendations are extrapolated from general guidelines for the management of HFrEF. In contrast, the beneficial impact of abstinence from methamphetamines is much more well-defined.

This narrative review describes the assessment and management of MAC with a specific emphasis on contemporary medical therapy and the evidence supporting its use in this patient population. The pathophysiology and cardiovascular manifestations of chronic methamphetamine use are explored, including a holistic approach to managing patients with MAC.

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