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Abstract

Left ventricular dysfunction triggers the activation of the sympathetic nervous system, providing inotropic support to the failing heart and concomitantly increasing the risk of atrial fibrillation (AF). The cardiovascular effects of cannabis have been characterized as biphasic on the autonomic nervous system with an increased sympathetic effect at low doses and an inhibitory sympathetic activity at higher doses. It is unknown if the autonomic effect of cannabis impacts the occurrence of AF in patients with heart failure (HF). We used data from the Healthcare Cost and Utilization Project-National Inpatient Sample for patients admitted with a diagnosis of HF in 2014. The outcome variable was the diagnosis of AF, with the main exposure being cannabis use. We identified a cannabis user group and a 1:1 propensity-matched non-cannabis user group, each having 3,548 patients. We then estimated the odds of AF diagnosis in cannabis users. An estimated 3,950,392 patients were admitted with a diagnosis of HF in the United States in 2014. Among these, there were 17,755 (0.45%) cannabis users. In the matched cohort, cannabis users were less likely to have AF (19.08% vs 21.39%; AOR 0.87 [0.77 to 0.98]). In conclusion, cannabis users have lower odds of AF when compared with nonusers, which was not explained by co-morbid conditions, age, insurance type, and socioeconomic status.
Left ventricular dysfunction triggers the activation of the sympathetic nervous system, providing
inotropic support to the failing heart and concomitantly increasing the risk of atrial fibrillation
(AF). The cardiovascular effects of cannabis have been characterized as biphasic on the
autonomic nervous system with an increased sympathetic effect at low doses and an inhibitory
sympathetic activity at higher doses. It is unknown if the autonomic effect of cannabis impacts
the occurrence of AF in patients with heart failure (HF). We used data from the Healthcare Cost
and Utilization Project–National Inpatient Sample for patients admitted with a diagnosis of HF in
2014. The outcome variable was the diagnosis of AF, with the main exposure being cannabis
use. We identified a cannabis user group and a 1:1 propensity-matched non–cannabis user
group, each having 3,548 patients. We then estimated the odds of AF diagnosis in cannabis
users. An estimated 3,950,392 patients were admitted with a diagnosis of HF in the United
States in 2014. Among these, there were 17,755 (0.45%) cannabis users. In the matched
cohort, cannabis users were less likely to have AF (19.08% vs 21.39%; AOR 0.87 [0.77 to
0.98]). In conclusion, cannabis users have lower odds of AF when compared with nonusers,
which was not explained by co-morbid conditions, age, insurance type, and socioeconomic
status.
... The observed cardiovascular benefits of MC outlined here in this case support current trends in the literature, that is, cell culture, [5] systematic reviews, [6] receptor cloning, and agonist/antagonist studies. [7][8][9] The case also supports the hypothesis that components of cannabis appear to be cardioprotective, [4][5][6][7][8][9] operating via a vast distribution of the ECS and noncannabinoid secondary messenger systems. ...
... The observed cardiovascular benefits of MC outlined here in this case support current trends in the literature, that is, cell culture, [5] systematic reviews, [6] receptor cloning, and agonist/antagonist studies. [7][8][9] The case also supports the hypothesis that components of cannabis appear to be cardioprotective, [4][5][6][7][8][9] operating via a vast distribution of the ECS and noncannabinoid secondary messenger systems. Cannabis-induced acute MI (AMI), however, is a paradoxical feature of cannabis; occurring in a small percentage of users without a history of CAD or other appreciable factors. ...
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Rationale: First discovered in 1990, the endocannabinoid system (ECS) was initially shown to have an intimate relationship with central areas of the nervous system associated with pain, reward, and motivation. Recently, however, the ECS has been extensively implicated in the cardiovascular system with contractility, heart rate, blood pressure, and vasodilation. Emerging data demonstrate modulation of the ECS plays an essential role in cardio metabolic risk, atherosclerosis, and can even limit damage to cardiomyocytes during ischemic events. Patient concerns: This case describes a 63-year-old man who presented to a primary care physician for a medical cannabis (MC) consult due to unstable angina (UA) not relieved by morphine or cardiac medications; having failed all first- and second-line polypharmaceutical therapies. The patient reported frequent, unprovoked, angina and exertional dyspnea. Diagnosis: Having a complex cardiac history, the patient first presented 22 years ago after a suspected myocardial infarction. He re-presented in 2010 and underwent stent placement at that time for inoperable triple-vessel coronary artery disease (CAD) which was identified via percutaneous transluminal coronary angioplasty. UA developed on follow-up and, despite medical management over the past 6 years, became progressively debilitating. Interventions and outcomes: In conjunction with his standard cardiac care, patient had a gradual lessening of UA-related pain, including frequency and character, after using an edible form of MC (1:1 cannabidiol:Δ9-tetrahydrocannabinol). Following continued treatment, he ceased long-term morphine treatment and described the pain as no longer crippling. As demonstrated by his exercise tolerance tests, the patient experienced an improved functional capacity and reported an increase in his daily functioning, and overall activity. Lessons: This case uniquely highlights MC in possibly reducing the character, quality, and frequency of UA, whereas concordantly improving functional cardiac capacity in a patient with CAD. Additional case reports are necessary to verify this.
... Contrarily, in patients with congestive heart failure, a recent study suggested that cannabis users have lower odds of AF compared with nonusers, which was not explained by comorbid conditions, age, insurance type, and socioeconomic status. 59 There are case reports, however, of cannabis triggering lethal arrhythmias in patients with preexistent cardiomyopathies. 60 Finally, synthetic cannabinoids also were associated with AF, and the effect of those drugs appears more potent than that of natural plants. ...
Modifiable risk factor management is becoming one of the 3 treatment pillars in atrial fibrillation management along with anticoagulation as well as conventional rate and rhythm control strategies. Preventive therapies, such as reducing blood pressure and treating obstructive sleep apnea, are paramount in the strategy of preventing atrial fibrillation. Identification of new modifiable risk factors and triggers also could help in the global strategy to reduce atrial fibrillation. This article covers alcohol intake, tobacco smoking, caffeine, chocolate, cannabis use, and air pollution as social risk factors related to lifestyle habits that potentially could contribute to atrial fibrillation development.
... Therefore, statistically, we cannot determine what is causing the increased rate of arrhythmiascannabis use, depression, or the interaction between the two. A different study, that analyzed the same National Inpatient Sample (NIS) database as Desai et al. and matched patients with heart failure and cannabis use disorder to people with the same characteristics but without cannabis use disorder, showed that cannabis use was associated with a lower prevalence of atrial fibrillation: adjusted odds-ratio 0.87, 95% confidence interval 0.77 to 0.98, p = 0.018 [13]. Yet, it is important to note that the arrhythmia prevalence observed in the study by Desai et al. is substantially higher than expected in this age group: the prevalence of arrhythmias during the 6 th decade of lifeolder population with a higher expected prevalenceis estimated as being less than 3% [14]. ...
... The present finding of greater heart arrhythmia in cannabis-using patients, in the total sample, and TUD and non-TUD subgroups, is consistent with a study finding a higher rate of arrhythmia in drivers who were positive for cannabis, relative to control drivers (24). In contrast, a study in patients with heart failure revealed lower rates of atrial fibrillation in cannabis-using, compared to control, participants (25); the discrepancy in findings may be due to the difference in the patient samples, with the present study including patients not selected for heart failure or other cardiovascular conditions and the present evaluation of arrhythmia as opposed to atrial fibrillation. ...
Article
Background: Understanding the potential impact of cannabis use on cardiovascular health is increasingly important as cannabis use rises in the U.S. Objectives: This study evaluated the associations between regular cannabis use, with and without tobacco co-use, and cardiovascular outcomes. Methods: Analysis of a limited dataset obtained through IBM Watson Health Explorys, a platform integrating electronic health record data. Matched controls using Mahalanobis distance within propensity score calipers were defined for: 1) cannabis-using patients (n = 8,944; 43% female); and subgroups of cannabis-using patients: 2) with an encounter diagnosis for tobacco use disorder (TUD; n = 4,682); and 3) without a TUD diagnosis (non-TUD; n = 4,262). Patients had ≥1 blood pressure measurement and blood chemistry lab result in the MetroHealth System (Cleveland, Ohio). Cannabis-using patients had an encounter diagnosis of cannabis abuse/dependence and/or ≥2 cannabis-positive urine drug screens. Control patients, with no cannabis-use-documentation, were matched to the cannabis-using patients on demographics, residential zip code median income, body mass index, and, for the total sample, TUD-status. Outcomes were encounter diagnosis (yes/no) of cerebrovascular accident (CVA), heart arrhythmia, myocardial infarction, subarachnoid hemorrhage (SAH), and all-cause mortality. Results: TUD-patients had the greatest prevalence of cardiovascular disease, regardless of cannabis-use indication. In the total sample and non-TUD subgroup, regular cannabis use was significantly associated with greater risk for CVA, arrhythmia, SAH, and mortality. In the TUD subgroup, regular cannabis use was significantly associated with greater risk for arrhythmia and SAH. Conclusions: Cannabis use is associated with significantly greater risk of adverse cardiovascular diagnoses and overall death, particularly in non-tobacco users.
Article
Marijuana use among all age groups has been increasing, including among older adults aged ≥65 years. There is a lack of epidemiologic data examining arrhythmia risk among users of marijuana. We evaluated cross-sectional associations between current and past marijuana smoking and arrhythmias among 1485 participants from the Multiethnic Study of Atherosclerosis who underwent extended ambulatory electrocardiographic monitoring with the Zio Patch XT. Outcomes included premature atrial contractions, runs of supraventricular tachycardia, premature ventricular contractions, and runs of nonsustained ventricular tachycardia (NSVT). Compared with never users, participants reporting current use of marijuana (n = 40, 3%) had more supraventricular tachycardia/day (adjusted geometric mean ratio [GMR] 1.42, 95% confidence interval [CI] 0.87 to 2.32), more premature atrial contractions/hour (GMR 1.22, 95% CI 0.72, 2.13), and more NSVT/day (GMR 1.28, 95% CI 0.95 to 1.73); although, CIs overlapped 1. Additionally, more frequent marijuana use was associated with more runs of NSVT/day (GMR 1.56, 95% CI 1.13, 2.17). In conclusion, our results suggest that current marijuana use may be associated with a greater burden of arrhythmias. There is a need for additional research, mainly using a prospective design, to clarify if marijuana use causes atrial and ventricular arrhythmias or other cardiovascular complications among older adults.
Article
Cannabis, or marijuana, has potential therapeutic and medicinal properties related to multiple compounds, particularly Δ-9-tetrahydrocannabinol and cannabidiol. Over the past 25 years, attitudes toward cannabis have evolved rapidly, with expanding legalization of medical and recreational use at the state level in the United States and recreational use nationally in Canada and Uruguay. As a result, the consumption of cannabis products is increasing considerably, particularly among youth. Our understanding of the safety and efficacy of cannabis has been limited by decades of worldwide illegality and continues to be limited in the United States by the ongoing classification of cannabis as a Schedule 1 controlled substance. These shifts in cannabis use require clinicians to understand conflicting laws, health implications, and therapeutic possibilities. Cannabis may have therapeutic benefits, but few are cardiovascular in nature. Conversely, many of the concerning health implications of cannabis include cardiovascular diseases, although they may be mediated by mechanisms of delivery. This statement critically reviews the use of medicinal and recreational cannabis from a clinical but also a policy and public health perspective by evaluating its safety and efficacy profile, particularly in relationship to cardiovascular health.
Article
Introduction: Cannabis use results in elevation of heart rate and blood pressure immediately after use, primarily due to sympathetic nervous system stimulation and parasympathetic nervous system inhibition. These effects may precipitate cardiac dysrhythmia. The objective of our study was to analyze systematically the pertinent medical literature regarding the putative association between cannabis use and cardiac dysrhythmia. Methods: We queried PubMed, Google Scholar, and OpenGrey, and reviewed results for relevance. We graded clinical trials, observational and retrospective studies, case series and reports using Oxford Centre for Evidence-Based Medicine guidelines. Results: The relevant publications identified included one Level I systematic review and meta-analysis of six human studies, 16 Level II studies with 6,942 subjects, nine Level III studies with 3,797,096 subjects and two systematic and scoping reviews with 30 cases. Cannabis-induced tachycardia was highlighted in 17 of 28 (61%) Level I–III articles followed by a generalized description of dysrhythmia in eight (29%). Specific dysrhythmias noted in the Level I–III articles included atrial fibrillation, atrial flutter, atrioventricular block, premature ventricular contractions, premature atrial contractions, ventricular tachycardia, and ventricular fibrillation. Other reported findings on electrocardiogram included ST segment elevation, P, and T wave changes. Only one Level III study reported a decreased risk of atrial fibrillation from cannabis use in patients hospitalized for heart failure (Odds ratio = 0.87). There were 39 case series (Level IV) and case reports (Level V) with 42 subjects. Average age was 30 ± 12 years, and only ten (24%) were female. The most common dysrhythmia mentioned in the Level IV and V articles was ventricular fibrillation (21%), followed by atrial fibrillation (19%), ventricular tachycardia (12%), third degree atrioventricular block (12%), and asystole (12%). There were four cases (10%) of symptomatic bradycardia. Notable electrocardiographic changes included ST segment elevation (29%), Brugada pattern in leads V1, V2 (14%), and right bundle branch block (12%). There were eight cases of cardiac arrest, of whom five expired. Conclusion: Cannabis use is associated with increased risk of cardiac dysrhythmia, which is rare but may be life-threatening. Clinicians and nurses should inquire about acute and chronic cannabis use in their patients presenting with tachycardia, bradycardia, dysrhythmia, chest pain, and/or unexplained syncope. Patients who use cannabis should be educated on this deleterious association, especially those with underlying cardiac disease or risk factors.
Article
Background: Protein-energy malnutrition (PEM) diminishes amino acid and energy availability, impairing the body's healing capability after injury, such as in myocardial damage following acute myocardial infarction (AMI). Aims: We sought to investigate the influence of PEM on clinical outcomes of AMI. Methods: We identified records with a primary discharge diagnosis of AMI from the Nationwide Inpatient Sample (2012-2014), stratified by concomitant PEM. We matched PEM to no-PEM (1:1) using a greedy algorithm-based propensity methodology and estimated the impact of PEM on health outcomes (SAS 9.4). Results: Of the 332,644 hospitalizations for AMI, 11,675 had concomitant PEM accounting for roughly $US 1.5 billion and over 119,792 hospital days. PEM was associated with older age (74.43- vs. 66.90-years; P < 0.0001), female sex (49.19% vs. 38.44%; P < 0.0001), black race (12.78% vs. 10.46%; P < 0.0001), and higher comorbidity burden (Deyo > 3: 32.77% vs. 16.69%; P < 0.0001). After propensity matching, PEM was associated with higher mortality (Adjusted odds ratio [AOR]: 1.59 [1.46-1.73]), cardiogenic shock (AOR: 2.26 [2.08-2.44]), discharge to secondary facilities (AOR: 2.21 [2.10-2.33]), charges ($135,500 [$131,956-139,139] vs. $81,084 [$79,241-82,970]), cardiac artery bypass surgery (AOR:1.81 [1.66-1.97]), intra-aortic balloon pump placement (AOR: 1.83 [1.65-2.04]) and longer length of stay (10.15- vs. 5.52-days). Conclusions: PEM is a predisposing factor for devastating clinical outcomes among AMI hospitalizations. Higher prevention, identification and management of PEM among high-risk individuals (older age, female sex, and black race) residing in the community are needed.
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