Cannabis abuse association with takotsubo cardiomyopathy in Pakistan

Takotsubo cardiomyopathy or TTC, also known as stress-induced cardiomyopathy, is a form of heart failure (HF) that causes acute and reversible changes in the heart’s shape and affects adults without any clear explanation. One characteristic feature of TTC is the abnormal circumferential pattern of the left ventricular wall motion that leads to regional ballooning of the left ventricle. Its pathophysiology is not yet understood as the signs and symptoms are similar to acute coronary syndrome.1 The prevalence of TTC is increasing over the years, and recently, it has been reported that around 2% (10% if only women are considered) of all patients who present with acute coronary syndrome have TTC.2 Various risk factors for TTC have been identified through studies, which include both emotional and physical stressors. This condition usually affects elderly females over 55 years and is triggered by smoking, alcohol abuse, anxiety, and hyperlipidaemia.3 A study by Stiermaier et al. 4 investigated the relationship between the two important types of TTC. According to their study, there is usually a prior emotional trigger that defines the type of TTC. The prevalence of negative emotional stressors led to broken heart syndrome, whereas the prevalence of positive emotional stressors was associated with happy heart syndrome. Both forms lead to acute myocardial infarction characteristic of TTC. Moreover, happy heart syndrome is more prevalent in men. A study by Thomas et al. 5 mentioned the mechanisms behind cannabis abuse and TTC. According to their study, one adverse effect of cannabis abuse is on the coronary microcirculation which leads to TTC. Another study by Ma et al. 6 proposed that the effects of stress and cannabis abuse are additive and cause hyper-activation in the amygdala which in the long term can lead to TTC. Moreover, they mention that there are similar findings between TTC, cannabis abuse, and stress in brain imaging studies. Their findings support the argument that cannabis abuse is a potential risk factor for TTC. An important limitation of this study is that the number of brain imaging studies probing the causes of TTC is small and thus requires further investigation. There has been an increasing trend of legalization of cannabis in many countries and its abuse in developing countries is a major concern. The outcomes of this study have highlighted significant worries for countries such as Pakistan, as ∼3.6% of adults in the population engage in cannabis abuse, and about 4 million individuals are classified as cannabis users.7 Moreover, the traditional risk factors for HF such as older age, male sex, hypertension, and diabetes are prevalent in Asia.8 The incidence of drug abuse, including cannabis, is higher among impoverished individuals in Pakistan. Poverty can lead to decreased self-esteem, which may result in feelings of guilt, shame, and reduced self-worth. Individuals with low self-esteem are more susceptible to developing substance use disorders. The recent economic decline in Pakistan has resulted in an increase in poverty rates. Despite conducting an extensive online search on PubMed and PakMediNet using the search term [Takotsubo Cardiomyopathy AND (Cannabis Abuse OR Marijuana Abuse) AND Pakistan]; we could not find any original studies investigating cannabis abuse as a risk factor of TTC in Pakistan. However, studies conducted in other countries can provide insight into TTC occurrence and risk factors in the Indian subcontinent. Recent studies have demonstrated effective treatment options for cannabis abuse such as motivational enhancement therapy (MET), cognitive behavioural therapy (CBT), and contingency management (CM) along with family-based treatment plans. Of these, MET and CBT have proven to cause maximum rehabilitation of cannabis abusers. Motivational enhancement therapy consists of 45- to 90-min individual sessions and focuses on motivating the drug abuser to change. Cognitive behavioural therapy is a 60-min counselling session that revolves around teaching patients skills relevant to quitting cannabis abuse. These options should be made available at rehabilitation centres. Moreover, these methods can only be useful if a culture of reporting drug abusers to rehabilitation centres established across the country is encouraged. According to a position paper on HF prevention, improving the levels of modifiable risk factors such as substance abuse is important in strategies to prevent HF. Supervised detox and proper medical intervention is necessary for high-risk groups.8 Such a milestone can be achieved by raising awareness and educating the public about TTC, including its association with cannabis use, and the importance of maintaining a drug-free and stress-free lifestyle. Healthcare facilities can play a pivotal role here by arranging pamphlets for the public on this topic. Such efforts could be instrumental in educating the public about this severe issue and potentially saving numerous lives. Not applicable.