(4) Cannabis-Induced Atypical Stress Cardiomyopathy: A Case Report

Introduction
Cannabis is the most commonly used illicit substance in the United States, with approximately 22.2 million Americans utilizing cannabis each month for medicinal and recreational use (1). This case report demonstrates atypical stress cardiomyopathy in a young adult secondary to cannabis use. Given common public perception of cannabis as a benign substance, it is essential for providers to be vigilant of its potential for cardiovascular morbidity.

Case Presentation
A 32 year old Caucasian male with a past medical history of chronic neck and back pain presented to the emergency room for seizure-like activity. The patient reported to have used a concentrated delta 9-tetrahydrocannabinol (THC) vaping product in the days leading up to hospitalization. Preliminary laboratory work-up was significant for anion gap metabolic acidosis, acute kidney injury (creatinine 2.9 mg/dL), elevated lactate (7 mmol/L), and troponemia (7.9 ng/mL). Urine drug screen (UDS) was positive for cannabinoids. Electrocardiogram showed sinus rhythm with premature supraventricular complexes. Echocardiogram showed a severely reduced left ventricular (LV) ejection fraction of 20% and akinesia of all mid-LV walls. Left heart catheterization revealed normal coronary arteries with low LV end-diastolic pressure. Cardiac magnetic resonance (CMR) reported no late gadolinium enhancement. Patient was eventually discharged home on levetiracetam 750 mg two times per day, metoprolol succinate 50 mg daily, and lisinopril 5 mg daily.

Discussion
Cannabis impacts the cardiovascular system through the endocannabinoid system (ECS) by stimulating cannabinoid receptors, mainly cannabinoid receptor 1 (CB1). CB1 activation directly affects sympathetic and parasympathetic tone, favoring a hyperadrenergic state, decreased cerebral blood flow, arterial vasospasms, procoagulation and increased oxidative stress (2). Thus, emerging evidence suggests a direct role of the ECS in the pathogenesis of stress cardiomyopathy (SC) (2).

Cannabis use is a risk factor for transient ventricular regional ballooning which is seen in Takotsubo cardiomyopathy (3). This case report demonstrates that a healthy young male, without other causes for cardiomyopathy, could develop SC related to heavy cannabis use.

The classic pattern of SC is apical akinesia. However, this patient exhibited akinesia of mid-LV walls, consistent with the mid-ventricular variant or atypical SC. SC variants have been reported, with the mid-ventricular variant notable in patients with cannabis or stimulant use (4,5).

Myocarditis can mimic SC. The patient’s CMR demonstrated myocardial edema in T2-weighted imaging without evidence of one T1-based criterion per the Lake Louise criteria (6). In addition, the patient’s rapid clinical recovery suggests SC rather than myocarditis (7). To address the catecholamine excess and systolic dysfunction, the patient was placed on a beta blocker and an angiotensin converting enzyme inhibitor upon discharge.

Although the patient reported THC use, the UDS cannot differentiate between THC or synthetic cannabinoids. In the future, it may be helpful to determine if THC or synthetic cannabis is the cause of cardiovascular complications due to their unique pharmacological properties.

Conclusion
More research is warranted to firmly establish the link between cannabis use and the development of SC. It is vital for clinicians to be cognizant of the effects of cannabis on the cardiovascular system.

References: 1. “Fast Facts and Fact Sheets.” Centers for Disease Control and Prevention, 12 May 2017, www.cdc.gov/marijuana/fact-sheets.htm.

2. Latif Z, Garg N. The Impact of Marijuana on the Cardiovascular System: A Review of the Most Common Cardiovascular Events Associated with Marijuana Use. J Clin Med. 2020 Jun 19;9(6):1925. doi: 10.3390/jcm9061925. PMID: 32575540; PMCID: PMC7355963.

3. Singh A, Agrawal S, Fegley M, Manda Y, Nanda S, Shirani J. Marijuana (cannabis) use is an independent predictor of stress cardiomyopathy in younger men. Circulation. 29 Mar 2018;2016;134:A14100

4. Meera SJ, Vallabhaneni S, Shirani J. Cannabis-induced basal-mid-left ventricular stress cardiomyopathy: A case report. Int J Crit Illn Inj Sci. 2020 Sep;10(Suppl 1):49-52. doi: 10.4103/IJCIIS.IJCIIS_25_20. Epub 2020 Sep 16. PMID: 33376691; PMCID: PMC7759071.

5. Chandraprakasam S, Kanuri S, Hunter C. Mid-Ventricular Variant of Dobutamine-Induced Stress Cardiomyopathy. Res Cardiovasc Med. 2015 May 23;4(2):e25223. Doi: 10.5812/cardiovascmed.4(2)2015.25223. PMID: 26425489; PMCID: PMC4584264.

6. Ferreira VM, Schulz-Menger J, Holmvang G, Kramer CM, Carbone I, Sechtem U, Kindermann I, Gutberlet M, Cooper LT, Liu P, Friedrich MG. Cardiovascular Magnetic Resonance in Nonischemic Myocardial Inflammation: Expert Recommendations. J Am Coll Cardiol. 2018 Dec 18;72(24):3158-3176. doi: 10.1016/j.jacc.2018.09.072. PMID: 30545455.

7. Kumar S, Mostow N, Grimm RA. Quick resolution of takotsubo cardiomyopathy: a brief review. Echocardiography. 2008 Nov;25(10):1117-20. doi: 10.1111/j.1540-8175.2008.00775.x. PMID: 18986394.

Diversity, Equity, and Inclusion: With legalization of cannabis becoming more common, it is important for healthcare providers to acknowledge how communities of racial and ethnic minorities could be affected disproportionally by the negative consequences of cannabis use. In our practice we will diligently educate learners and colleagues of other specialties so that they could impart that knowledge to underserved communities in the future. With the knowledge of the harms of cannabis use, we will continue to incorporate motivational interviewing in our daily interactions with cannabis users who are not yet ready to quit.