ST-segment elevation acute myocardial infarction & stoned: a bad trip

In 2021, 1 in 17 adults aged 15–64 worldwide had used a drug in the previous 12 months, with an estimated of 296 million total users which represents 5.8% of this age group. Cannabis was the most widely used drug, with 219 million users (4.3% of the world’s adult population), with an upward pattern and a decreasing trend in the gender gap, with, and increasing trend in use among women. The next most popular substances were amphetamines (36 million users), cocaine (22 million), and substances of the ecstasy type (20 million).1 During the same time in Europe, it was estimated that 83.4 million adults 29% had used an illicit drug, with cannabis also being the most widely used substance (22 million), followed by stimulants such as cocaine, 3, 4-methylenedioxy-N-methamphetamine (MDMA), and amphetamines (7 million).2 In this issue of EHJACC, a multi-center, prospective, observational study conducted in 39 intensive cardiac care units (ICCUs) in France, analysed the effect of recent drug use on in-hospital prognosis in patients with ST-segment elevation acute myocardial infarction (STEMI). A systematic urine multidrug test was obtained from all patients with STEMI over a 2-week period in 2021. A total of 325 patients were included of whom 12.6% tested positive for drugs (cannabis 11.1%, opioids 4.6%, cocaine 1.2%, and MDMA 0.6%). Ventricular arrhythmia and major adverse cardiac events (MACEs) defined by death, resuscitated cardiac arrest, or cardiogenic shock were more frequent in recreational drug users. The use of recreational drugs was associated with MACEs after adjustment (OR = 13.1; 95% CI 3.4–54.6).3 These important results are in agreement with the available epidemiological data on the prevalence of drug use and its effect on cardiovascular disease. However, several issues related to the context of initial care in emergency departments and intensive care units should be discussed. First, the use of qualitative drug screening tests has the possibility of including false positives, due to cross-reactions with other drugs, or non-recent consumption. This is the case of cannabis, which can be positive in these tests up to 2 weeks after its usage, or after being in consumption settings, with the patient having a passive or involuntary exposure to the drug. On the other hand, there can also be false negatives.4 This can be the case in patients using novel psychoactive substances (NPS). These drugs are easily available through Internet sites, in many cases not yet illegalized, with greater potency and more acute effects than the ‘classic’ drugs they mimic. Furthermore, NPS is not detectable with the usual drug tests used at hospital level (such as the one used by the authors).2,5,6 This broad group of recreational substances includes not only cathinones, as the authors rightly point out, but also psychedelic-type substances—with the structure and effects of the lysergic acid diethylamide (LSD) spectrum-, opiates-, and ultra-potent benzodiazepines and, importantly, synthetic cannabinoids (Figure 1).7,8 Second, A self-reported consumption rate of 53.7% was observed. A much higher rate than previously reported in studies carried out in emergency departments, which were at best half that found in the study. This is in contrast with the rate of poly drug use detected is 39% which was somewhat lower.9 Classic recreative drugs and novel psychoactive substances. The Drugs Wheel by Mark Adley (www.thedrugswheel.com) is licensed under a Creative Commons Attribution-Non Commercial-Share Alike 4.0 International License. In addition to the direct consumption of NPS, its use has been detected as a cutting substance for the drugs detected by Narcocheck and other similar qualitative tests, without the patient being aware of it and reporting its use to the health staff.10 Thirdly, a priori, the very high percentage of cannabis-positive cases in relation to cardiovascular disease admissions (87.8%) is striking, especially considering the well-known relationship between cocaine use and the occurrence of cardiovascular events. The role of exogenous cannabinoids (phytocannabinoids such as delta-9-tetrahydrocannabinol and synthetic cannabinoids) in acute cardiovascular pathology and the pathogenesis of chronic cardiovascular pathology is also already well-known.11 Therefore, in case of an acute cardiovascular event, the patient should be asked about their use with the same accuracy as for the use of cocaine, MDMA, or amphetamines, even if their pathophysiology is not sympathomimetic. The increased agonist activity of phytocannabinoids on CB1 and CB2 cannabinoid receptors,12 but especially the synthetic cannabinoids effects13 are of concern for physicians taking care of acutely ill patients. This increase in potency is most likely linked to the higher rate of emergency department visits and acute cardiovascular events among cannabis users, either alone or in association with other drugs. The rising trend towards the legalization of its usage, whether recreational or under the umbrella of the so-called medical cannabis (a subterfuge for its covert legalization) when there are already cannabinoids approved for pharmaceutical use, and hence, the trivialization of its use augurs a troubling cardiovascular scenario in the near future. On the other hand, there was no relationship between MACEs with tobacco use. In this sense, one aspect to be taken into account should be the growing and little-studied use of vapers with synthetic cannabinoids in their liquid formulation.14 Finally, the study proposes to investigate recreational drug use in all STEMI patients under 50 years of age. This is a reasonable approach, although arbitrary, because in the near future, it is likely that a high prevalence of drug use in an increasingly aging European society in which patients from 50 to 60 years will be as active as the one immediately preceding it.15 Although it seems reasonable to make all patients with acute cardiovascular events (including cerebral vascular events) a drug test. This laboratory report has important biases due to the current low detection of NPS at the standard available tests. It should be accompanied by a directed anamnesis that investigating acute or chronic drug use. As the authors demonstrate, this consumption has prognostic implications, and its early detection would anticipate the possibility of MACEs occurring. In addition, once discharged from the ICCUs, the patient should be informed of the risks of drug use and, if necessary, referred to drug dependence services. None declared. No new data were generated or analysed in support of this research.