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Canadian Journal of Cardiology

Early-Onset Cardiovascular Disease From Cocaine, Amphetamines, Alcohol, and Marijuana

      Abstract

      Cardiovascular disease (CVD), a disease typically associated with aging and the definitive leading cause of death worldwide, now threatens young and middle-aged populations. Recreational abuse of alcohol, marijuana, cocaine, and amphetamine-type stimulants has been an escalating public health problem for decades, but now use of these substances has become a significant contributor to early-onset CVD. While this remains a global phenomenon, the epicentre of substance abuse is rooted in North America, where it has been exacerbated by the response to the COVID-19 pandemic. For the first time in history, the United States crossed 100,000 overdose-related deaths in a calendar year. Sadly, Canada’s recreational drug abuse problem closely mirrors that of the US. This is indicative of the larger public health crisis, as we now know that these substances are cardiotoxic and are contributing to the rising levels of premature chronic CVD, including hypertension, arrhythmias, heart failure, stroke, myocardial infarction, arterial dissection, sudden cardiac death, and early mortality.

      Résumé

      Les maladies cardiovasculaires (MCV), maladies généralement associées au vieillissement et la principale cause de décès dans le monde, menacent désormais les populations jeunes et d'âge moyen. L'abus récréatif d'alcool, de marijuana, de cocaïne et de stimulants de type amphétamine constitue un problème de santé publique croissant depuis des décennies, mais aujourd'hui, la consommation de ces substances contribue de manière significative à l'apparition précoce de MCV. Bien que ce phénomène soit mondial, l'épicentre de l'abus de ces substances est ancré en Amérique du Nord, où il a été exacerbé par la réponse à la pandémie de COVID-19. Pour la première fois dans l'histoire, les États-Unis ont franchi le cap des 100 000 décès par overdose au cours d'une année civile. Malheureusement, le problème de l'abus de drogues récréatives au Canada reflète étroitement celui des États-Unis. Cela est révélateur d'une crise de santé publique plus vaste, car nous savons maintenant que ces substances sont cardiotoxiques et contribuent à l'augmentation des niveaux de MCV chroniques prématurées, notamment l'hypertension, les arythmies, l'insuffisance cardiaque, les accidents vasculaires cérébraux, l'infarctus du myocarde, la dissection artérielle, la mort cardiaque subite et une mortalité précoce.
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      References

        • Barbieri M.
        The contribution of drug-related deaths to the US disadvantage in mortality.
        Int J Epidemiol. 2019; 48: 945-953
      1. Centers for Disease Control and Prevention. Wide-Ranging Data for Epidemiologic Research (WONDER). Available at: https://wonder.cdc.gov/. Accessed xxxx.

      2. Special Advisory Committee on the Epidemic of Opioid Overdoses, Public Health Agency of Canada. Opioid and stimulant-related harms in Canada. Available at: https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants. Accessed xxxx.

        • Ritchie H.
        • Roser M.
        Opioids, cocaine, cannabis and illicit drugs. Our World in Data.
        (Available at:) (Accessed xxxx)
        • Qureshi A.I.
        • Suri M.F.
        • Guterman L.R.
        • Hopkins L.N.
        Cocaine use and the likelihood of nonfatal myocardial infarction and stroke: data from the Third National Health and Nutrition Examination Survey.
        Circulation. 2001; 103: 502-506
        • Vongpatanasin W.
        • Mansour Y.
        • Chavoshan B.
        • Arbique D.
        • Victor R.G.
        Cocaine stimulates the human cardiovascular system via a central mechanism of action.
        Circulation. 1999; 100: 497-502
        • Wilbert-Lampen U.
        • Seliger C.
        • Zilker T.
        • Arendt R.M.
        Cocaine increases the endothelial release of immunoreactive endothelin and its concentrations in human plasma and urine: reversal by coincubation with sigma-receptor antagonists.
        Circulation. 1998; 98: 385-390
        • Havranek E.P.
        • Nademanee K.
        • Greyburn P.A.
        • Eichhorn E.J.
        Endothelium-dependent vasorelaxation is impaired in cocaine arteriopathy.
        J Am Coll Cardiol. 1996; 28: 1168-1174
        • Mo W.
        • Singh A.K.
        • Arruda J.A.
        • Dunea G.
        Role of nitric oxide in cocaine-induced acute hypertension.
        Am J Hypertens. 1998; 11: 708-714
        • Perreault C.L.
        • Morgan K.G.
        • Morgan J.P.
        Effects of cocaine on intracellular calcium handling in cardiac and vascular smooth muscle.
        NIDA Res Monogr. 1991; 108: 139-153
        • Fogo A.
        • Superdock K.R.
        • Atkinson J.B.
        Severe arteriosclerosis in the kidney of a cocaine addict.
        Am J Kidney Dis. 1992; 20: 513-515
        • Kibayashi K.
        • Mastri A.R.
        • Hirsch C.S.
        Cocaine induced intracerebral hemorrhage: analysis of predisposing factors and mechanisms causing hemorrhagic strokes.
        Hum Pathol. 1995; 26: 659-663
        • Kim S.T.
        • Park T.
        Acute and chronic effects of cocaine on cardiovascular health.
        Int J Mol Sci. 2019; 20: 584
        • Havakuk O.
        • Rezkalla S.H.
        • Kloner R.A.
        The cardiovascular effects of cocaine.
        J Am Coll Cardiol. 2017; 70: 101-113
        • Office on Drugs and Crime United Nations
        World drug report 2021.
        (Available at:) (Accessed xxxx)
      3. Government of Canada. Canadian Tobacco, Alcohol and Drugs Survey 2013: detailed tables. Available at: https://www.canada.ca/en/health-canada/services/canadian-alcohol-drugs-survey/2013-supplementary-tables.html. Accessed xxxx.

        • Government of Canada
        Canadian Tobacco, Alcohol and Drugs Survey 2015: detailed tables. Available at:.
        (Accessed xxxx)
        • Government of Canada
        Canadian Tobacco, Alcohol and Drugs Survey 2017: detailed tables. Available at:.
        (Accessed xxxx)
        • Arenas D.J.
        • Beltran S.
        • Zhou S.
        • Goldberg L.R.
        Cocaine, cardiomyopathy, and heart failure: a systematic review and meta-analysis.
        Sci Rep. 2020; 1019795
        • Diercks D.B.
        • Fonarow G.C.
        • Kirk J.D.
        • et al.
        Illicit stimulant use in a United States heart failure population presenting to the emergency department (from the Acute Decompensated Heart Failure National Registry Emergency Module).
        Am J Cardiol. 2008; 102: 1216-1219
        • Greve D.
        • Funke J.
        • Khairi T.
        • et al.
        Cocaine-related aortic dissection: what do we know?.
        Braz J Cardiovasc Surg. 2020; 35: 764-769
        • Dean J.H.
        • Woznicki E.M.
        • O’Gara P.
        • et al.
        Cocaine-related aortic dissection: lessons from the International Registry of Acute Aortic Dissection.
        Am J Med. 2014; 127: 878-885
        • Egashira K.
        • Morgan K.G.
        • Morgan J.P.
        Effects of cocaine on excitation-contraction coupling of aortic smooth muscle from the ferret.
        J Clin Invest. 1991; 87: 1322-1328
        • Rezkalla S.H.
        • Mazza J.J.
        • Kloner R.A.
        • Tillema V.
        • Chang S.H.
        Effects of cocaine on human platelets in healthy subjects.
        Am J Cardiol. 1993; 72: 243-246
        • Siegel A.J.
        • Mendelson J.H.
        • Sholar M.B.
        • et al.
        Effect of cocaine usage on C-reactive protein, von Willebrand factor, and fibrinogen.
        Am J Cardiol. 2002; 89: 1133-1135
        • Moliterno D.J.
        • Lange R.A.
        • Gerard R.D.
        • et al.
        Influence of intranasal cocaine on plasma constituents associated with endogenous thrombosis and thrombolysis.
        Am J Med. 1994; 96: 492-496
        • Lange R.A.
        • Cigarroa R.G.
        • Yancy Jr., C.W.
        • et al.
        Cocaine-induced coronary-artery vasoconstriction.
        N Engl J Med. 1989; 321: 1557-1562
        • Benzaquen B.S.
        • Cohen V.
        • Eisenberg M.J.
        Effects of cocaine on the coronary arteries.
        Am Heart J. 2001; 142: 402-410
        • Ebersberger U.
        • Sudarski S.
        • Schoepf U.J.
        • et al.
        Atherosclerotic plaque burden in cocaine users with acute chest pain: analysis by coronary computed tomography angiography.
        Atherosclerosis. 2013; 229: 443-448
        • Dressler F.A.
        • Malekzadeh S.
        • Roberts W.C.
        Quantitative analysis of amounts of coronary arterial narrowing in cocaine addicts.
        Am J Cardiol. 1990; 65: 303-308
        • Patrizi R.
        • Pasceri V.
        • Sciahbasi A.
        • et al.
        Evidence of cocaine-related coronary atherosclerosis in young patients with myocardial infarction.
        J Am Coll Cardiol. 2006; 47: 2120-2122
        • Lucena J.
        • Blanco M.
        • Jurado C.
        • et al.
        Cocaine-related sudden death: a prospective investigation in south-west Spain.
        Eur Heart J. 2010; 31: 318-329
        • Mahtta D.
        • Ramsey D.
        • Krittanawong C.
        • et al.
        Recreational substance use among patients with premature atherosclerotic cardiovascular disease.
        Heart. 2021; 107: 650-656
        • Corrado D.
        • Basso C.
        • Poletti A.
        • et al.
        Sudden death in the young. Is acute coronary thrombosis the major precipitating factor?.
        Circulation. 1994; 90: 2315-2323
        • Andrews P.
        Cocaethylene toxicity.
        J Addict Dis. 1997; 16: 75-84
        • Arendt M.
        • Munk-Jorgensen P.
        • Sher L.
        • Jensen S.O.
        Mortality among individuals with cannabis, cocaine, amphetamine, MDMA, and opioid use disorders: a nationwide follow-up study of Danish substance users in treatment.
        Drug Alcohol Depend. 2011; 114: 134-139
        • Degenhardt L.
        • Singleton J.
        • Calabria B.
        • et al.
        Mortality among cocaine users: a systematic review of cohort studies.
        Drug Alcohol Depend. 2011; 113: 88-95
        • Sanvisens A.
        • Hernandez-Rubio A.
        • Zuluaga P.
        • et al.
        Long-term outcomes of patients with cocaine use disorder: an 18-years addiction cohort study.
        Front Pharmacol. 2021; 12625610
        • Hsue P.Y.
        • Salinas C.L.
        • Bolger A.F.
        • Benowitz N.L.
        • Waters D.D.
        Acute aortic dissection related to crack cocaine.
        Circulation. 2002; 105: 1592-1595
        • Kiluk B.D.
        • Babuscio T.A.
        • Nich C.
        • Carroll K.M.
        Smokers vs snorters: do treatment outcomes differ according to route of cocaine administration?.
        Exp Clin Psychopharmacol. 2013; 21: 490-498
        • Hall W.C.
        • Talbert R.L.
        • Ereshefsky L.
        Cocaine abuse and its treatment.
        Pharmacotherapy. 1990; 10: 47-65
        • Lord K.C.
        • Shenouda S.K.
        • McIlwain E.
        • et al.
        Oxidative stress contributes to methamphetamine-induced left ventricular dysfunction.
        Cardiovasc Res. 2010; 87: 111-118
        • Mendelson J.
        • Uemura N.
        • Harris D.
        • et al.
        Human pharmacology of the methamphetamine stereoisomers.
        Clin Pharmacol Ther. 2006; 80: 403-420
        • Darke S.
        • Duflou J.
        • Kaye S.
        Prevalence and nature of cardiovascular disease in methamphetamine-related death: a national study.
        Drug Alcohol Depend. 2017; 179: 174-179
        • Hedegaard H.
        • Minino A.M.
        • Spencer M.R.
        • Warner M.
        Drug overdose deaths in the United States, 1999-2020. NCHS Data Brief no. 428.
        December 2021 (, December 2021. Available at:) (Accessed xxxx)
        • Nishimura M.
        • Ma J.
        • Fox S.
        • et al.
        Characteristics and outcomes of methamphetamine abuse among veterans with heart failure.
        Am J Cardiol. 2019; 124: 907-911
        • Reddy P.K.V.
        • Ng T.M.H.
        • Oh E.E.
        • Moady G.
        • Elkayam U.
        Clinical characteristics and management of methamphetamine-associated cardiomyopathy: state-of-the-art review.
        J Am Heart Assoc. 2020; 9e016704
        • Kevil C.G.
        • Goeders N.E.
        • Woolard M.D.
        • et al.
        Methamphetamine use and cardiovascular disease.
        Arterioscler Thromb Vasc Biol. 2019; 39: 1739-1746
        • Schwarzbach V.
        • Lenk K.
        • Laufs U.
        Methamphetamine-related cardiovascular diseases.
        ESC Heart Fail. 2020; 7: 407-414
        • O’Keefe E.L.
        • Torres-Acosta N.
        • O’Keefe J.H.
        • et al.
        Takotsubo syndrome: cardiotoxic stress in the COVID era.
        Mayo Clin Proc Innov Qual Outcomes. 2020; 4: 775-785
        • Ferreira V.M.
        • Marcelino M.
        • Piechnik S.K.
        • et al.
        Pheochromocytoma is characterised by catecholamine-mediated myocarditis, focal and diffuse myocardial fibrosis, and myocardial dysfunction.
        J Am Coll Cardiol. 2016; 67: 2364-2374
        • Schurer S.
        • Klingel K.
        • Sandri M.
        • et al.
        Clinical characteristics, histopathological features, and clinical outcome of methamphetamine-associated cardiomyopathy.
        JACC Heart Fail. 2017; 5: 435-445
        • Voskoboinik A.
        • Ihle J.F.
        • Bloom J.E.
        • Kaye D.M.
        Methamphetamine-associated cardiomyopathy: patterns and predictors of recovery.
        Intern Med J. 2016; 46: 723-727
        • Wijetunga M.
        • Seto T.
        • Lindsay J.
        • Schatz I.
        Crystal methamphetamine-associated cardiomyopathy: tip of the iceberg?.
        J Toxicol Clin Toxicol. 2003; 41: 981-986
        • Ito H.
        • Yeo K.K.
        • Wijetunga M.
        • Seto T.B.
        • Tay K.
        • Schatz I.J.
        A comparison of echocardiographic findings in young adults with cardiomyopathy: with and without a history of methamphetamine abuse.
        Clin Cardiol. 2009; 32: e18-22
        • Yeo K.K.
        • Wijetunga M.
        • Ito H.
        • et al.
        The association of methamphetamine use and cardiomyopathy in young patients.
        Am J Med. 2007; 120: 165-171
        • Zhang M.
        • Lv D.
        • Zhou W.
        • et al.
        The levels of triglyceride and total cholesterol in methamphetamine dependence.
        Medicine (Baltimore). 2017; 96e6631
        • Karch S.B.
        • Stephens B.G.
        • Ho C.H.
        Methamphetamine-related deaths in San Francisco: demographic, pathologic, and toxicologic profiles.
        J Forensic Sci. 1999; 44: 359-368
        • Chin K.M.
        • Channick R.N.
        • Rubin L.J.
        Is methamphetamine use associated with idiopathic pulmonary arterial hypertension?.
        Chest. 2006; 130: 1657-1663
        • Zamanian R.T.
        • Hedlin H.
        • Greuenwald P.
        • et al.
        Features and outcomes of methamphetamine-associated pulmonary arterial hypertension.
        Am J Respir Crit Care Med. 2018; 197: 788-800
        • Kissela B.M.
        • Khoury J.C.
        • Alwell K.
        • et al.
        Age at stroke: temporal trends in stroke incidence in a large, biracial population.
        Neurology. 2012; 79: 1781-1787
        • Lappin J.M.
        • Darke S.
        • Farrell M.
        Stroke and methamphetamine use in young adults: a review.
        J Neurol Neurosurg Psychiatry. 2017; 88: 1079-1091
        • Westover A.N.
        • McBride S.
        • Haley R.W.
        Stroke in young adults who abuse amphetamines or cocaine: a population-based study of hospitalised patients.
        Arch Gen Psychiatry. 2007; 64: 495-502
        • Huang M.C.
        • Yang S.Y.
        • Lin S.K.
        • et al.
        Risk of cardiovascular diseases and stroke events in methamphetamine users: a 10-year follow-up study.
        J Clin Psychiatry. 2016; 77: 1396-1403
        • Griswold M.G.
        • Fullman N.
        • Hawley C.
        • et al.
        Alcohol use and burden for 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.
        Lancet. 2018; 392: 1015-1035
        • O’Keefe E.L.
        • DiNicolantonio J.J.
        • O’Keefe J.H.
        • Lavie C.J.
        Alcohol and CV health: Jekyll and Hyde J-curves.
        Prog Cardiovasc Dis. 2018; 61: 68-75
        • Grucza R.A.
        • Sher K.J.
        • Kerr W.C.
        • et al.
        Trends in adult alcohol use and binge drinking in the early 21st-century United States: a meta-analysis of 6 national survey series.
        Alcohol Clin Exp Res. 2018; 42: 1939-1950
        • Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services
        Binge alcohol use.
        (Available at:) (Accessed xxxx)
        • Chung T.
        • Creswell K.G.
        • Bachrach R.
        • Clark D.B.
        • Martin C.S.
        Adolescent binge drinking.
        Alcohol Res. 2018; 39: 5-15
        • Kann L.
        • McManus T.
        • Harris W.A.
        • et al.
        Youth risk behaviour surveillance—United States, 2015.
        MMWR Surveill Summ. 2016; 65: 1-174
        • Addolorato G.
        • Vassallo G.A.
        • Antonelli G.
        • et al.
        Binge drinking among adolescents is related to the development of alcohol use disorders: results from a cross-sectional study.
        Sci Rep. 2018; 812624
        • Ettinger P.O.
        • Wu C.F.
        • de la Cruz Jr., C.
        • et al.
        Arrhythmias and the “holiday heart”: alcohol-associated cardiac rhythm disorders.
        Am Heart J. 1978; 95: 555-562
        • Csengeri D.
        • Sprunker N.A.
        • di Castelnuovo A.
        • et al.
        Alcohol consumption, cardiac biomarkers, and risk of atrial fibrillation and adverse outcomes.
        Eur Heart J. 2021; 42: 1170-1177
        • Marcus G.M.
        • Vittinghoff E.
        • Whitman I.R.
        • et al.
        Acute consumption of alcohol and discrete atrial fibrillation events.
        Ann Intern Med. 2021; 174: 1503-1509
        • Waszkiewicz N.
        • Szulc A.
        • Zwierz K.
        Binge drinking-induced subtle myocardial injury.
        Alcohol Clin Exp Res. 2013; 37: 1261-1263
        • Sidorenkov O.
        • Nilssen O.
        • Nieboer E.
        • Kleshchinov N.
        • Grjibovski A.M.
        Premature cardiovascular mortality and alcohol consumption before death in Arkhangelsk, Russia: an analysis of a consecutive series of forensic autopsies.
        Int J Epidemiol. 2011; 40: 1519-1529
        • Ram P.
        • Lo K.B.
        • Shah M.
        • Patel B.
        • Rangaswami J.
        • Figueredo V.M.
        National trends in hospitalisations and outcomes in patients with alcoholic cardiomyopathy.
        Clin Cardiol. 2018; 41: 1423-1429
        • Urbano-Marquez A.
        • Estruch R.
        • Fernandez-Sola J.
        • et al.
        The greater risk of alcoholic cardiomyopathy and myopathy in women compared with men.
        JAMA. 1995; 274: 149-154
        • Bostwick J.M.
        Blurred boundaries: the therapeutics and politics of medical marijuana.
        Mayo Clin Proc. 2012; 87: 172-186
        • DeFilippis E.M.
        • Bajaj N.S.
        • Singh A.
        • et al.
        Marijuana use in patients with cardiovascular disease: JACC review topic of the week.
        J Am Coll Cardiol. 2020; 75: 320-332
        • Desai R.
        • Patel U.
        • Deshmukh A.
        • Sachdeva R.
        • Kumar G.
        Burden of arrhythmia in recreational marijuana users.
        Int J Cardiol. 2018; 264: 91-92
        • Hodcroft C.J.
        • Rossiter M.C.
        • Buch A.N.
        Cannabis-associated myocardial infarction in a young man with normal coronary arteries.
        J Emerg Med. 2014; 47: 277-281
        • Pasha A.K.
        • Clements C.Y.
        • Reynolds C.A.
        • et al.
        Cardiovascular effects of medical marijuana: a systematic review.
        Am J Med. 2021; 134: 182-193
        • Herning R.I.
        • Better W.E.
        • Tate K.
        • Cadet J.L.
        Cerebrovascular perfusion in marijuana users during a month of monitored abstinence.
        Neurology. 2005; 64: 488-493
        • Jones R.T.
        Cardiovascular system effects of marijuana.
        J Clin Pharmacol. 2002; 42: 58S-63S
        • Karabulut A.
        • Cakmak M.
        ST segment elevation myocardial infarction due to slow coronary flow occurring after cannabis consumption.
        Kardiol Pol. 2010; 68: 1266-1268
        • Desai R.
        • Patel U.
        • Sharma S.
        • et al.
        Recreational marijuana use and acute myocardial infarction: insights from Nationwide Inpatient Sample in the United States.
        Cureus. 2017; 9e1816
        • Rumalla K.
        • Reddy A.Y.
        • Mittal M.K.
        Recreational marijuana use and acute ischemic stroke: A population-based analysis of hospitalised patients in the United States.
        J Neurol Sci. 2016; 364: 191-196
        • Mittleman M.A.
        • Mintzer D.
        • Maclure M.
        • Tofler G.H.
        • Sherwood J.B.
        • Muller J.E.
        Triggering of myocardial infarction by cocaine.
        Circulation. 1999; 99: 2737-2741
        • Jouanjus E.
        • Leymarie F.
        • Tubery M.
        • Lapeyre-Mestre M.
        Cannabis-related hospitalisations: unexpected serious events identified through hospital databases.
        Br J Clin Pharmacol. 2011; 71: 758-765
        • Kadri A.N.
        • Wilner B.
        • Hernandez A.V.
        • et al.
        Geographic trends, patient characteristics, and outcomes of infective endocarditis associated with drug abuse in the United States From 2002 to 2016.
        J Am Heart Assoc. 2019; 8e012969
        • Njoroge L.W.
        • Al-Kindi S.G.
        • Koromia G.A.
        • ElAmm C.A.
        • Oliveira G.H.
        Changes in the association of rising infective endocarditis with mortality in people who inject drugs.
        JAMA Cardiol. 2018; 3: 779-780
        • Lin A.
        • Nah G.
        • Vittinghoff E.
        • Marcus G.M.
        Substance use and associated risk of incident atrial fibrillation [abstract].
        Circulation. 2021; 144A11349
        • Aung S.
        • Nah G.
        • Vittinghoff E.
        • et al.
        Population-level analyses of alcohol consumption as a predictor of acute atrial fibrillation episodes [abstract].
        Circulation. 2021; 144A12236
        • Grant B.F.
        • Saha T.D.
        • Ruan W.J.
        • et al.
        Epidemiology of DSM-5 drug use disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions—III.
        JAMA Psychiatry. 2016; 73: 39-47
        • Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services
        Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health. HHS publication no. PEP19-5068, NSDUH series H-54. Available at:.
        (Accessed xxxx)
        • National Center for Health Statistics, Centers for Disease Control and Prevention
        Provisional drug overdose death counts.
        (Available at:) (Accessed xxxx)
        • Amor-Salamanca A.
        • Guzzo-Merello G.
        • Gonzalez-Lopez E.
        • et al.
        Prognostic impact and predictors of ejection fraction recovery in patients with alcoholic cardiomyopathy.
        Rev Esp Cardiol (Engl Ed). 2018; 71: 612-619
        • Guzzo-Merello G.
        • Segovia J.
        • Dominguez F.
        • et al.
        Natural history and prognostic factors in alcoholic cardiomyopathy.
        JACC Heart Fail. 2015; 3: 78-86