Medical and Recreational Marijuana: Implications for Cardiovascular Health and Public Health

Last Updated: July 28, 2022


Disclosure: Dr. DeFilippis has no disclosures. Dr. Bhatt discloses the following relationships: Advisory Board: Cardax, CellProthera, Cereno Scientific, Elsevier Practice Update Cardiology, Level Ex, Medscape Cardiology, PhaseBio, PLx Pharma, Regado Biosciences; Board of Directors: Boston VA Research Institute, Society of Cardiovascular Patient Care, TobeSoft; Chair: American Heart Association Quality Oversight Committee; Data Monitoring Committees: Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Cleveland Clinic (including for the ExCEED trial, funded by Edwards), Contego Medical (Chair, PERFORMANCE 2), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo), Population Health Research Institute; Honoraria: American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org; Vice-Chair, ACC Accreditation Committee), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim; AEGIS-II executive committee funded by CSL Behring), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (Editor in Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), K2P (Co-Chair, interdisciplinary curriculum), Level Ex, Medtelligence/ReachMD (CME steering committees), MJH Life Sciences, Population Health Research Institute (for the COMPASS operations committee, publications committee, steering committee, and USA national co-leader, funded by Bayer), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME steering committees); Other: Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Chair), VA CART Research and Publications Committee (Chair); Research Funding: Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Cardax, Chiesi, CSL Behring, Eisai, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, Idorsia, Ironwood, Ischemix, Lexicon, Lilly, Medtronic, Pfizer, PhaseBio, PLx Pharma, Regeneron, Roche, Sanofi Aventis, Synaptic, The Medicines Company; Royalties: Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); Site Co-Investigator: Biotronik, Boston Scientific, CSI, St. Jude Medical (now Abbott), Svelte; Trustee: American College of Cardiology; Unfunded Research: FlowCo, Merck, Novo Nordisk, Takeda.
Pub Date: Wednesday, Aug 05, 2020
Author: Ersilia M. DeFilippis, MD and Deepak L. Bhatt MD, MPH
Affiliation: Dr. DeFilippis - Division of Cardiology, Columbia University Irving Medical Center; Dr. Bhatt - Division of Cardiovascular Medicine, Brigham and Women’s Hospital, and Harvard Medical School

In recent years, an increasing number of states have legalized marijuana for recreational use. As of March 2020, 47 states and the District of Columbia allow some form of marijuana use.1 This has coincided with increasing use in the population, particularly among young adults, as well as the emergence of potent synthetic cannabinoids. The active cannabinoids in marijuana plants are tetrahydrocannabinol (THC) and cannabidiol (CBD), both of which can have effects on the cardiovascular system directly and indirectly through CBD receptors located in various organ tissues.

Importantly, many of the cannabis products on the market, such as topical CBD products, are not subject to approval by the Food and Drug Administration (FDA). In cases where the FDA has tested CBD content, many products did not contain the concentrations reported on the labels.2

Although medicinal marijuana has been used for certain conditions and for alleviation of symptoms (including anorexia, nausea, vomiting, and pain), there have not been any documented cardiovascular benefits associated with their use. In fact, there is a growing body of evidence that suggests that marijuana use may have deleterious acute and chronic cardiovascular health effects.

In this newly released statement, the American Heart Association summarizes and provides guidance regarding the effects of both medical and recreational marijuana use on cardiovascular health.1

In the acute setting, THC stimulates the sympathetic nervous system leading to increased heart rate, myocardial oxygen demand, and platelet activation. In one pivotal study, Mittelman and colleagues found that the risk of myocardial infarction was 4.8-fold higher in those patients who had smoked marijuana within 1 hour of symptom onset.3 Similarly, in a population of patients < 50 years old with a first myocardial infarction, marijuana use was associated with increased cardiovascular and all-cause mortality.4

Marijuana use has also been associated with hypertension, pre-diabetes, cardiomyopathy, arrhythmias, arteritis, cardiogenic shock, stroke, and sudden cardiac death.5 It is important to note that most of these associations are reported in retrospective observational studies without granular data regarding doses of marijuana or formulations.

It is particularly important for the cardiovascular community to be aware of drug-drug interactions with cannabinoids in various forms. Given the wide variety of products available, each with differing potencies, doses, and routes of administration, these interactions can be unpredictable. Data suggest that THC and CBD can serve as inducers and inhibitors through the cytochrome P450 pathway leading to increasing or decreasing doses of cardiovascular medications including statins, anti-arrhythmic agents, anti-hypertensives, coumadin, sodium glucose cotransporter-2 inhibitors, and anti-rejection medications for patients following heart transplantation.5,6 These concerns may be even more salient in our aging population given the prevalence of polypharmacy in this group. Thus, a complete and thorough history with respect to marijuana use, recreational or medicinal, should be consistently obtained by physicians.

These public health safety concerns extend to other organ systems. Marijuana use, particularly when it is inhaled, has also been associated with increased risk of e-cigarette or vaping product use-associated lung injury (EVALI), more severe presentations of coronavirus disease 2019 infection, as well as an association with the development of testicular cancer.7,8

This comprehensive guidance document by the American Heart Association is an excellent step forward in educating physicians and health care professionals, patients, and public health officials but highlights the need for continued prospective research and rigorously performed studies to further evaluate the cardiovascular risks associated with marijuana use. Collaboration between legislators, physicians, public health officials, and scientists is needed to help define policies, educate the public, and support ongoing research.

Citation


Page RL 2nd, Allen LA, Kloner RA, Carriker CR, Martel C, Morris AA, Piano MR, Rana JS, Saucedo JF; on behalf of the American Heart Association Clinical Pharmacology Committee and Heart Failure and Transplantation Committee of the Council on Clinical Cardiology; Council on Basic Cardiovascular Sciences; Council on Cardiovascular and Stroke Nursing; Council on Epidemiology and Prevention; Council on Lifestyle and Cardiometabolic Health; and Council on Quality of Care and Outcomes Research. Medical marijuana, recreational cannabis, and cardiovascular health: a scientific statement from the American Heart Association [published online ahead of print August 5, 2020]. Circulation. doi: 10.1161/CIR.0000000000000883.

References


  1. Page RL 2nd, Allen LA, Kloner RA, Carriker CR, Martel C, Morris AA, Piano MR, Rana JS, Saucedo JF; on behalf of the American Heart Association Clinical Pharmacology Committee and Heart Failure and Transplantation Committee of the Council on Clinical Cardiology; Council on Basic Cardiovascular Sciences; Council on Cardiovascular and Stroke Nursing; Council on Epidemiology and Prevention; Council on Lifestyle and Cardiometabolic Health; and Council on Quality of Care and Outcomes Research. Medical marijuana, recreational cannabis, and cardiovascular health: a scientific statement from the American Heart Association [published online ahead of print August 5, 2020]. Circulation. doi: 10.1161/CIR.0000000000000883.
  2. Food and Drug Administration. FDA regulation of cannabis and cannabis-derived products, including cannabidiol (CBD). Available at: https://www.fda.gov/news-events/ public-health-focus/fda-regulation-cannabis-and-cannabis-derived-products-including- cannabidiol-cbd. Accessed December 20, 2019.
  3. Mittleman MM, Lewis RA, Maclure M, Sherwood JB, Muller JE. Triggering myocardial infarction by marijuana. Circulation. 2001;103:2805-2809.
  4. DeFilippis EM, Singh A, Divakaran S, Gupta A, Collins BL, Biery D, Qamar A, Fatima A, Ramsis M, Pipilas D, Rajabi R, Eng M, Hainer J, Klein J, Januzzi JL, Nasir K, Di Carli MF, Bhatt DL, Blankstein R. Cocaine and marijuana use among young adults with myocardial infarction. J Am Coll Cardiol. 2018; 71:2540-2551.
  5. DeFilippis EM, Baja NS, Singh A, Malloy R, Givertz MM, Blankstein R, Bhatt DL, Vaduganathan M. Marijuana use in patients with cardiovascular disease. JACC. 2020; 75: 320-332.
  6. Brown JD, Winterstein AG. Potential adverse drug events and drug-drug interactions with medicinal and consumer cannabidiol (CBD) use. J Clin Med. 2019; 8: pii: e989.
  7. Centers for Disease Control. CDC, States Update Number of Hospitalized EVALI Cases and EVALI Deaths. Available at: https://www.cdc.gov/tobacco/basic_information/ecigarettes/severe-lung-disease.html. Accessed March 10, 2020.
  8. Ghasemiesfe M, Barrow B, Leonard S, Keyhani S, Korenstein D. Association between marijuana use and risk of cancer: A systematic review and meta-analysis. JAMA Netw Open. 2019; 2(11): e1916318.

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-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --