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Cocaine and Marijuana Use Among Young Adults With MI
Study Questions:
What is the prevalence of marijuana and cocaine use in young patients (≤50 years) with myocardial infarction (MI), and is there an association with long-term outcomes?
Methods:
The authors conducted a retrospective study from two large academic medical centers that included patients who experienced a type 1 MI at ≤50 years between 2000 and 2016. Cocaine and/or marijuana use was determined by review of records for patient-reported or toxicology detection within the week prior to MI presentation. Outcomes studied were cardiovascular mortality and all-cause mortality, and were verified by the Social Security Administration’s Death Master File. Multivariable risk adjustment was performed using variables that had significant univariate association with the outcome of interest. Median follow-up time was 11.2 years (interquartile range, 7.3-14.2 years).
Results:
The study cohort consisted of 2,097 patients with type 1 MI (mean age 44.0 ± 5.1 years); 19.3% were female, and 73% were white. Cocaine use was present in 99 patients (4.7%), and marijuana use was present in 125 patients (6.0%). Patients with cocaine and/or marijuana use were younger at the time of their MI (median 44 years vs. 45 years, p < 0.001) and male (86.2% vs. 80.1%, p = 0.03). Patients with substance abuse had significantly lower rates of diabetes (14.7% vs. 60.8%, p = 0.05) and hyperlipidemia (45.7% vs. 60.8%, p < 0.001); however, tobacco use was significantly higher in the substance abuse group (70.3% vs. 49.1%, p < 0.001). The incidence of cardiac arrest at the time of MI presentation was higher in the substance abuse group (8.0% vs. 3.5%, p = 0.003).
Patients with substance abuse had significantly higher all-cause mortality compared with patients without substance abuse (18.8% vs. 11.3% p = 0.001). After adjusting for age, sex, diabetes, hypertension, peripheral vascular disease, smoking, high-density lipoprotein cholesterol (HDL-C), triglycerides, revascularization, creatinine, medications at discharge, and length of stay, the hazard ratio for all-cause death was 1.99 (95% confidence interval [CI], 1.35-2.97; p = 0.001) for any substance use, 2.09 (95% CI, 1.25-3.50; p = 0.005) for marijuana, and 1.91 (95% CI, 1.11-3.29; p = 0.02) for cocaine. For cardiovascular death, after adjusting for age, diabetes, hypertension, peripheral vascular disease, smoking, HDL-C, creatinine, medications and discharge, and length of stay, the hazard ratio was 2.22 (95% CI, 1.28-3.87; p = 0.005) for substance abuse, 2.13 (95% CI, 1.03-4.42; p = 0.042) for marijuana, and 2.32 (95% CI, 1.11-4.85) for cocaine.
Conclusions:
In this retrospective observational study, cocaine and/or marijuana use was prevalent in patients age 50 and younger presenting with type 1 MI. The use of cocaine and/or marijuana is associated with higher all-cause and cardiovascular mortality compared to patients without substance abuse.
Perspective:
The work by DeFilippis et al., is an important contribution to the body of data supporting that substance abuse is a risk factor for developing premature MI. The lower prevalence of traditional risk factors among cocaine and/or marijuana users presenting with MI suggests that substance abuse plays an important role in overcoming an otherwise low atherosclerotic cardiovascular disease (ASCVD) risk profile compared to nondrug user patients of similar age. This work reinforces the negative effects of cocaine use on cardiovascular health, which is a more well-understood risk factor for MI. This study also revealed an association of marijuana with higher all-cause and cardiovascular mortality in young patients with type 1 MI. This is a particularly interesting finding, especially in the setting of changing public opinion (increasingly licit) regarding cannabis. While this is a retrospective study and thus has limitations, it does underscore that future research is needed to better delineate the effects of marijuana on the cardiovascular system. From a practice perspective, cardiovascular health care providers should screen for and council patients on the potential harms of cannabis and cocaine use with respect to ASCVD.
Keywords: Acute Coronary Syndrome, Cannabis, Cocaine, Diabetes Mellitus, Heart Arrest, Hyperlipidemias, Marijuana Abuse, Marijuana Smoking, Metabolic Syndrome, Myocardial Infarction, Primary Prevention, Risk Adjustment, Risk Factors, Tobacco Use, Young Adult
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