1. Cannabis - A Heartbreaker
Yannan J. Wang 1, Smeet Patel 1, Arun Nagabandi 2, Vishal Arora 1, Gyanendra Sharma 2, Jayanth Keshavamurthy 1
1Department of Radiology, 2Department of Cardiology, Medical College of Georgia at Augusta University, Augusta, GA
Fig 1.
Fig 2.
INTRODUCTION
Fig 1: EKG from the first episode demonstrates focal (1mm) ST elevation in inferior (II, III, aVF) and lateral (V5, V6) leads with no reciprocal ST depressions.
Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy or apical ballooning syndrome, classically follows periods of severe emotional or physical stress in the absence of significant coronary artery stenosis or permanent systolic dysfunction. It is most commonly seen in women over the age of 50, and is usually fully reversible, with rapid and complete recovery within weeks. ~5% of patients will have more than one episode – however, multiple episodes have not been known to cause cumulative heart damage.[1]
Fig 2: EKG from the second episode demonstrates focal (1-2mm) ST elevation in the anterolateral leads (V4, V5)
THC
MR enhancement
Cardiomyopathy
LEARNING OBJECTIVES
Identify typical presentations of Takotsubo cardiomyopathy, and differentiate it from other cardiac conditions
Integrate multi-modality imaging in evaluating Takotsubo cardiomyopathy
Appreciate the potentially rare but serious risk of marijuana use
Cardiac MRI from the second episode. A) Three-chamber delayed contrast shows more extensive scarring of the myocardium compared to before. B) Short-axis delayed contrast image depicts patchy areas of mid-myocardic enhancement. C) Four-chamber delayed contrast image shows patchy areas of mid-myocardic enhancement.
Cardiac MRI from the first episode.
A) Four-chambered delayed contrast shows scarring of the myocardium of the basal inferolateral wall. B) Short-axis delayed contrast depicts scarring of the lateral wall myocardium. The sub-endocardium is spared. C) Short-axis T2 image shows hyper-intensity in the inferolateral wall indicative of edema.
CASE INFORMATION
DISCUSSION
The link between marijuana use and cardiovascular disease has not been prospectively studied, and current literature is limited to scarce cases reports of marijuana-induced Takotsubo cardiomyopathy. However, this patient’s demographics and documented use of THC prior to both episodes of cardiomyopathy make a strong proposition for a possible association between the two. Therefore, it seems prudent to evaluate younger patients with high troponin for THC use.
A 17-year-old male presented to the Emergency Department with acute chest pain. He had a similar event 1 year prior, during which his workup revealed elevated troponin and CK isoenzyme. EKG showed ST elevation in the inferior and lateral leads. Subsequent cardiac catheterization displayed non-obstructed coronary arteries. Ensuing cardiac MRI ruled out acute myocardial infarction, but exhibited patchy myocardial enhancement suggestive of myocarditis.
During this visit, the patient presented similarly with ST elevation in the anterolateral leads (V4, V5), elevated troponin, creatinine kinase-MB isoenzyme, and white blood cell count. Emergent cardiac catheterization demonstrated mild apical ballooning without coronary occlusion, dissection, or spasm. Cardiac MRI re-depicted non-ischemic patchy myocardial enhancement, and the previous MRI was rendered a false positive.
Upon further questioning, the patient revealed heavy marijuana use, and his urine drug screen was positive for Tetrahydrocannabinol (THC) on both occasions.
Given the patient’s age, he should not have been predisposed to develop cardiomyopathy, let alone have two incidences within a year. Although identification of a specific entity or stress triggers can be difficult, the patient’s use of THC preceding each occurrence alludes to his marijuana usage potentially causing recurrent Takotsubo cardiomyopathy.
Associations between preceding marijuana use and Takotsubo cardiomyopathy have been documented sparsely.[2][3] Singh et. al. concluded that younger patients with less risk factors for cardiovascular disease were two times more likely to have Takostubo cardiomyopathy after marijuana use.[4] However, marijuana use in itself has also been linked to cardiac arrest due to acute coronary syndrome, myo-pericarditis, ventricular tachycardia, and arrhythmias.[5] Additionally, cannabis has been proposed to cause recurrent stress cardiomyopathy and more generally, cardiovascular disease, through stimulation or alteration of the endocannabinoid system.[6]
REFERENCES
Sharkey SW, Lesser JR, Maron BJ. Takotsubo (Stress) Cardiomyopathy. Circulation. 2011;124(18). doi: /circulationaha
Nogi M, Fergusson D, Chiaco JMC. Mid-ventricular Variant Takotsubo Cardiomyopathy Associated with Cannabinoid Hyperemesis Syndrome: A Case Report. Hawai’i Journal of Medicine & Public Health. 2014;73(4):
Baranchuk A, Johri AM, Simpson CS, Methot M, Redfearn DP. Ventricular fibrillation triggered by marijuana use in a patient with ischemic cardiomyopathy: a case report. Cases Journal. 2008;1:373. doi: /
Singh A, Agrawal S, Fegley M, et al. Marijuana (cannabis) use is an independent predictor of stress cardiomyopathy in younger men. American Heart Association 2016 Scientific Sessions; November 13, 2016; New Orleans, LA. Abstract S4054
Panayiotides IM. What is the Association of Cannabis Consumption and Cardiovascular Complications? Substance Abuse: Research and Treatment. 2015;9:1-3. doi: /SART.S21827.
Kaushik M, Alla VM, Madan R, Arouni AJ, Mohiuddin SM. Recurrent Stress Cardiomyopathy With Variable Regional Involvement: Insights Into Etiopathogenetic Mechanisms. Circulation. 2011;124(22). doi: /circulationaha