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Cannabis Abuse and Elevated Risk of Myocardial Infarction in the Young: A Population-Based Study

      To the Editor:
      Cannabis is the most commonly abused illicit drug in the world. Almost half of the US population have tried cannabis,

      Substance Abuse and Mental Health Services Administration. Results from the 2015 National Survey on Drug Use and Health: Detailed Tables. SAMHSA website. https://www.samhsa.gov/data/report/results-2015-national-survey-drug-use-and-health-detailed-tables. Accessed December 10, 2017.

      yet its effect on the cardiovascular system remains largely unknown.
      • Ravi D.
      • Ghasemiesfe M.
      • Korenstein D.
      • Cascino T.
      • Keyhani S.
      Associations between marijuana use and cardiovascular risk factors and outcomes: a systematic review.
      • Subramaniam V.N.
      • Menezes A.R.
      • DeSchutter A.
      • Lavie C.J.
      The cardiovascular effects of marijuana: are the potential adverse effects worth the high?.
      We investigated the incidence of myocardial infarction (MI) and its association with cannabis abuse in a contemporary cohort. We used an aggregated, multi-institutional database (Explorys, Inc.) to perform a retrospective cohort analysis on patients with encounters between October 2011 and September 2016. The primary outcome was the 3-year cumulative incidence of MI. Multiple logistic regression analyses were performed to explore the association between cannabis abuse, MI, and cardiovascular risk factors.
      We identified 292,770 patients with a history of cannabis abuse and 10,542,348 age- and sex-matched controls. The mean age was 37.4 ± 15 years; 59.2% were male; and 60.3% were white. Overall, the cannabis abuse group had a higher prevalence of cardiovascular risk factors, including hypertension, coronary artery disease, dyslipidemia, diabetes, and obesity, as well as a greater predilection for substance abuse (including tobacco, cocaine, and alcohol). The 3-year cumulative incidence of MI was significantly higher in the cannabis abuse group than in controls (1.37% vs 0.54%; relative risk [RR], 2.53; 95% CI, 2.45-2.61), with the most pronounced risk in the young and middle aged (peak RR, 4.78; 95% CI, 3.92-5.82 for women aged 40-44 years and peak RR, 3.05; 95% CI, 3.75-5.54 for men aged 35-39 years) (Figure). In multivariable analysis, cannabis abuse was significantly associated with incident MI (adjusted odds ratio, 1.72; 95% CI, 1.67-1.77; P<.0001), independent of advanced age, sex, hypertension, coronary artery disease, diabetes, and other substance abuse.
      Figure thumbnail gr1
      FigureThree-year cumulative incidence of myocardial infarction (MI) in the cannabis abuse group (green bars) compared with age-matched controls (blue bars), along with relative risk (RR) among men (brown line) and women (yellow line).
      The association between cannabis use and MI in the literature has thus far been limited and inconclusive.
      • Ravi D.
      • Ghasemiesfe M.
      • Korenstein D.
      • Cascino T.
      • Keyhani S.
      Associations between marijuana use and cardiovascular risk factors and outcomes: a systematic review.
      • Subramaniam V.N.
      • Menezes A.R.
      • DeSchutter A.
      • Lavie C.J.
      The cardiovascular effects of marijuana: are the potential adverse effects worth the high?.
      Two studies have examined the association between cannabis exposure and acute MI. The Determinants of Myocardial Infarction Onset Study identified 124 individuals with cannabis exposure 1 year before MI onset from 3882 acute MI cases.
      • Mittleman M.A.
      • Lewis R.A.
      • Maclure M.
      • Sherwood J.B.
      • Muller J.E.
      Triggering myocardial infarction by marijuana.
      The risk of MI was elevated 4.8 times within 60 minutes after smoking cannabis. In a more recent study, DeFilippis et al
      • DeFilippis E.M.
      • Singh A.
      • Divakaran S.
      • et al.
      Cocaine and marijuana use among young adults presenting with myocardial infarction: the Partners YOUNG-MI Registry.
      retrospectively examined 2097 young patients with type 1 MI, of whom 125 individuals had used cannabis. In this study, cannabis appeared to confer a significant increase in all-cause and cardiovascular mortality.
      Our study demonstrated a higher prevalence of cardiovascular risk factors (hypertension, diabetes, obesity, tobacco smoking, human immunodeficiency virus, alcohol, and cocaine abuse) in the cannabis abuse group, similar to previous cohort studies,
      • Rodondi N.
      • Pletcher M.J.
      • Liu K.
      • Hulley S.B.
      • Sidney S.
      Coronary Artery Risk Development in Young Adults (CARDIA) Study
      Marijuana use, diet, body mass index, and cardiovascular risk factors (from the CARDIA study).
      but seemingly at odds with the 2 studies described previously. This discrepancy may have been due to differences in study design and their inherent biases, as well as in our study. Limitations include reliance on Systematized Nomenclature of Medicine – Clinical Terms to identify cannabis exposure and MI in an aggregated database, whose severity and outcomes could not be ascertained otherwise. Although we attempted to adjust for confounders in our multivariable analysis, other unexpected confounders could have skewed our results.
      In conclusion, cannabis abuse may be associated with an elevated risk of MI independent of other cardiovascular risk factors, with higher relative risk in women and younger age groups. In the landscape of cannabis legalization across the United States, future epidemiological studies are needed for further delineation of this cardiovascular risk.

      Acknowledgements

      The authors would like to thank Dr David Zidar, MD, PhD, who helped prepare the presentation at the American College of Cardiology 17th national conference.

      References

      1. Substance Abuse and Mental Health Services Administration. Results from the 2015 National Survey on Drug Use and Health: Detailed Tables. SAMHSA website. https://www.samhsa.gov/data/report/results-2015-national-survey-drug-use-and-health-detailed-tables. Accessed December 10, 2017.

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        Associations between marijuana use and cardiovascular risk factors and outcomes: a systematic review.
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        The cardiovascular effects of marijuana: are the potential adverse effects worth the high?.
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        • Pletcher M.J.
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