Rupak Desai, MBBS, on Cannabis Use and Takotsubo Syndrome
According to the latest numbers from the National Institute on Drug Abuse, in 2018, more than 11.8 million young adults reported having used cannabis in the past year.1 With millions of US individuals using cannabis—and with the legalization of cannabis across the country being debated—a team of researchers sought to evaluate the association between cannabis use and Takotsubo syndrome.2
To conduct their study, the researchers used the National Inpatient Sample (2007-2014) to assess the prevalence and trends of Takotsubo syndrome among adults who used and did not use cannabis.
Compared with nonusers, individuals who use cannabis have a lower prevalence of Takotsubo syndrome. However, cannabis users have a more pronounced rising trend of Takotsubo syndrome and subsequent risk of in-hospital mortality than nonusers.
Rupak Desai, MBBS, a research fellow with the Division of Cardiology at the Atlanta VA Medical Center in Decatur, Georgia, was one of the study’s coauthors. Cardiology Consultant asked him about the team’s findings and how they should impact the conversations you have with patients.
CARDIOLOGY CONSULTANT: What was the impetus for your study?
Rupak Desai: Cannabis (marijuana) is the most commonly used psychoactive substance with approximately 200 million users worldwide.3,4 Chronic and/or habitual cannabis use has shown various adverse effects on the cardiovascular (CV) and pulmonary systems, in addition to significant psychiatric comorbidities. Recently, we have seen some isolated case reports suggesting a link between cannabis use and sympathomimetic cardiac effects such as tachycardia and hypertension. More recently, an association between cannabinoid use and stress-induced cardiomyopathy—or Takotsubo syndrome—and its related complications has also been recognized. However, large-scale data remained nonexistent in regard to whether cannabis use can affect trends in the prevalence and outcomes of Takotsubo syndrome; this incited us to analyze this hypothesis using the largest inpatient sample in the United States.
CARDIO CON: What are the key takeaways of your findings, and how should cardiologists implement those key findings into their practice?
RD: Key findings of our study include:
- There was an overall lower crude prevalence of Takotsubo syndrome among hospitalized cannabis users compared with nonusers but a more distinct rising trend of Takotsubo syndrome among cannabis users compared with nonusers from 2007 to 2014. This finding warrants more prospective longitudinal studies that could assess the correlation between rising trends in cannabis use and positive or negative impact in terms of incidence and outcomes among patients with Takotsubo syndrome.
- An adjusted multivariable analysis showed that cannabis use was associated with a 50% higher risk of in-hospital mortality among patients with Takotsubo syndrome. This remains an important finding as habitual cannabis use—along with polysubstance abuse and CV comorbidities—could increase risk of all-cause mortality among patients with Takotsubo syndrome, which is often self-limited if complications are diagnosed and managed in a timely fashion.
- Rates of cardiogenic shock, stroke, and respiratory failure, as well as the need for percutaneous ventricular assist devices, were higher among Takotsubo syndrome-related admissions with cannabis use. However, when multivariable analysis adjusted for confounders, there was no statistically significant impact of cannabis on CV complications. This needs to be further explored in future longitudinal studies to evaluate long-term effects based on mode, dose, and duration of cannabis use.
Increasing practitioners’ awareness of the higher in-hospital mortality and greater prevalence of Takotsubo syndrome among cannabis users with expectedly growing use in the near future may help address the rise of Takotsubo syndrome-related short-term and/or long-term adverse outcomes.
CARDIO CON: A patient with Takotsubo syndrome who uses cannabis presents to a cardiologist. What should be included in a conversation with this patient, and what do you recommend the end goal of that conversation be?
RD: Our understanding of the etiopathogenesis of Takotsubo syndrome is still evolving similarly to our understanding of the CV effects of cannabis use. Amidst a growing concern of polysubstance abuse, it is essential for cardiologists to screen Takotsubo syndrome or stress-related cardiomyopathies for concomitant cardiac risk factors and, more importantly, for a history of polysubstance use. The primary objective of the conversation would be to spread awareness to habitual cannabis users about possible severe complications, such as cardiogenic shock, arrhythmias, stroke, and venous thromboembolism, if they were to develop Takotsubo syndrome.
CARDIO CON: According to your study, polysubstance use was significantly higher among patients with Takotsubo syndrome who used cannabis than those who did not use cannabis. What is the importance of this finding? How should it impact the way cardiologists approach conversations or carry out treatment with these patients?
RD: Among those who had been admitted for Takotsubo syndrome, a history of polysubstance use was found to be significantly higher among cannabis users compared with nonusers. This included alcohol (24.4% vs 4.1%), cocaine (8.5% vs 0.4%), amphetamine (8.0% vs 0.2%), and tobacco smoking (64.8% vs 31.2%). This finding indicates a major underlying health care concern of polysubstance abuse among cannabis users, which could significantly increase patients’ risk of CV diseases, including Takotsubo syndrome.
My colleagues and I recommend that cardiologists thoroughly screen their patients with Takotsubo syndrome who have a history of cannabis use for concomitant substance abuse and potential pertinent CV effects. Although Takotsubo syndrome is most often self-limited, physicians should spread awareness about possible severe complications of Takotsubo syndrome, such as cardiogenic shock, arrhythmias, stroke, and venous thromboembolism—especially in habitual cannabis users.
CARDIO CON: What further research is needed in the area of cannabis and Takotsubo syndrome?
RD: Our results indicate a lower crude prevalence with rising trends of Takotsubo syndrome in cannabis users. However, this study did not include data on mode, dose, and duration of cannabis use or its impact on the prevalence and outcomes of Takotsubo syndrome; this could be interesting to see in future studies with more granular data.
Furthermore, we feel that the increasing trend and higher mortality despite lower overall prevalence needs some further investigation. It would also be interesting to see the different effects of medicinal and recreational use of cannabis on long-term CV health. Women are generally more predisposed to Takotsubo syndrome, so it remains unexplored whether cannabis use will augment their risk profile or be proven beneficial in curtailing the risk of Takotsubo syndrome with medicinal use of cannabis. We believe there are many questions yet to be answered by future studies.
- National Institute on Drug Abuse. What is the scope of marijuana use in the United States? Updated April 8, 2020. Accessed June 22, 2020. https://www.drugabuse.gov/publications/research-reports/marijuana/what-scope-marijuana-use-in-united-states
- Desai R, Desai A, Fong HK, e al. Prevalence, trends and in-hospital outcomes of Takotsubo syndrome among United States cannabis users. Int J Cardiol. 2020; S0167-5273(20)30466. doi:10.1016/j.ijcard.2020.05.088
- International Drug Policy Consortium. The world drug report 2019: perspectives on protecting public health. Published November 2019. Accessed June 24, 2020. http://fileserver.idpc.net/library/IDPC-analysis-to-UNODC-WDR-2019_EN.pdf
- United Nations Office on Drugs and Crime. Cannabis: a short review. Accessed June 24, 2020. https://www.unodc.org/documents/drug-prevention-and-treatment/cannabis_review.pdf