Marijuana: An Underappreciated Risk Factor for Acute Type A Aortic Dissection?
Keywords:aortic dissection, marijuana, tetrahydrocannabinol (THC), toxicology
Background: Stimulants such as cocaine and amphetamines are well-established risk factors for acute aortic dissection. Despite the fact that marijuana is the most commonly used illicit drug in the United States, its relationship to acute aortic syndromes has not been well studied.
Methods: A comprehensive retrospective review was undertaken of all consecutive patients who presented with acute Stanford type A aortic dissection from January 2017 to December 2019. Of 152 patients identified, 51 (33.6%) underwent comprehensive urine toxicology screening at clinical presentation. The characteristics and outcomes of the patients with urine results positive for tetrahydrocannabinol (THC) (n = 9, 17.6%) were compared with the 42 patients who had no evidence of recent marijuana consumption.
Results: Of the 51 dissection patients who underwent broad-spectrum urine toxicology screening upon presentation, 9 (17.6%) returned positive results for THC, a proportion higher than would be expected for the general population. All THC patients were male; 3 concurrently tested positive for cocaine, and 3 others had evidence of recent amphetamine use. The THC patients were significantly younger than the non-THC patients (mean ± standard deviation age 48 ± 11.3 versus 61.4 ± 12.3 years, respectively, P = .004). A greater proportion of the THC cohort had a known diagnosis of aortic aneurysm before the dissection (44.4% versus 4.8%, P = .006). All patients underwent expeditious surgical repair. Thirty-day mortality for the entire cohort of 51 patients was 19.6% (10 deaths); for the THC group, it was 11.1% (1 death). There was no difference in the incidence of major postoperative complications between the 2 groups.
Conclusion: Marijuana is the third most commonly used substance in the United States, after alcohol and tobacco. Although marijuana use is understudied, our results suggest that marijuana may be a contributing risk factor for acute type A aortic dissection, particularly in patients with other predisposing risk factors. Given the recent national trend to legalize marijuana, with the concomitant potential for exponential increases in its consumption, we suggest that the diagnosis of aortic dissection be considered earlier in any younger patient who presents with suggestive symptoms, especially if there is a history of recent marijuana use.
Barry RA, Glantz SA. Marijuana regulatory frameworks in four US states: An analysis against a public health standard. Am J Public Health 2018;108:914-923.
Carliner H, Brown QL, Sarvet AL, Hasin DS. Cannabis use, attitudes, and legal status in the U.S.: A review. Prev Med 2017;104:13-23.
Chase PB, Hawkins J, Mosier J, et al. Differential physiological and behavioral cues observed in individuals smoking botanical marijuana versus synthetic cannabinoid drugs. Clin Toxicol (Phila) 2016;54:14-19.
DeFilippis EM, Bajaj NS, Singh A, et al. Marijuana use in patients with cardiovascular disease. J Am Coll Cardiol 2020;75:320-332.
Desbois AC, Cacoub P. Cannabis-associated arterial disease. Ann Vasc Surg 2013;27:996-1005.
Eagle KA, Isselbacher EM, DeSanctis RW, International Registry for Aortic Dissection (IRAD) Investigators. Cocaine-related aortic dissection in perspective. Circulation 2002;105:1529-1530.
Gunderson EW, Haughey HM, Ait-Daoud N, Joshi AS, Hart CL. A survey of synthetic cannabinoid consumption by current cannabis users. Subst Abus 2014;35:184-189.
Hall W, Stjepanović D, Caulkins J, et al. Public health implications of legalising the production and sale of cannabis for medicinal and recreational use. Lancet 2019;394:1580-1590.
Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377-381.
Hasin DS. US epidemiology of cannabis use and associated problems. Neuropsychopharmacology 2018;43:195-212.
Hemli JM, DeLaney ER, Dholakia KR, et al. Rethinking the paradigm: Modern approach to proximal aortic reconstruction demonstrates excellent outcomes. Heart Surg Forum 2017;20:E092-E097.
Kilmer B. Recreational cannabis—Minimizing the health risks from legalization. N Engl J Med 2017;376:705-707.
Lindsay AC, Foale RA, Warren O, Henry JA. Cannabis as a precipitant of cardiovascular emergencies. Int J Cardiol 2005;104:230-232.
Lukas SE, Sholar M, Kouri E, Fukuzako H, Mendelson JH. Marihuana smoking increases plasma cocaine levels and subjective reports of euphoria in male volunteers. Pharmacol Biochem Behav 1994;48:715-721.
Martz G, Tankersley W, Mekala HM, Motiwala H. Rates of synthetic cannabinoid use in adolescents admitted to a treatment facility. Prim Care Companion CNS Disord 2018;20:17m02265.
Mason EK, Gak AE, Finno JG, Cannon RD, Jacoby JL. Thoracic aortic dissection associated with marijuana use. J Emerg Med 2019;57:235-237.
Maxwell JC, Mendelson B. What do we know now about the impact of the laws related to marijuana? J Addict Med 2016;10:3-12.
Mead A. Legal and regulatory issues governing cannabis and cannabis-derived products in the United States. Front Plant Sci 2019;10:697.
Mittlemen MA, Lewis RA, Maclure M, Sherwood JB, Muller JE. Triggering myocardial infarction by marijuana. Circulation 2001;103:2805-2809.
Oberbarnscheidt T, Miller NS. The impact of cannabidiol on psychiatric and medical conditions. J Clin Med Res 2020;12:393-403.
Palamar JJ, Barratt MJ. Synthetic cannabinoids: Undesirable alternatives to natural marijuana. Am J Drug Alcohol Abuse 2016;42:371-373.
ProCon.org. Legal Medical Marijuana States and DC. 2020. Available at https://medicalmarijuana.procon.org/legal-medical-marijuana-states-and-dc/ (Accessed January 27, 2021).
Richards JR, Bing ML, Moulin AK, et al. Cannabis use and acute coronary syndrome. Clin Toxicol 2019;57:831-841.
SAMHSA (Substance Abuse and Mental Health Services Administration). Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health (HHS Publication No. PEP19-5068, NSDUH Series H-54). 2019. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Available at: http://store.samhsa.gov/product/key-substance-use-and-mental-health-indicators-in-the-united-states-results-from-the-2018-national-survey-on-Drug-Use-and-Health/PEP19-5068 (Accessed January 27, 2021).
Sevigny EL, Pacula RL, Heaton P. The effects of medical marijuana laws on potency. Int J Drug Policy 2014;25:308-319.
Shah R, Berzingi C, Fan THM, Askari R, Khan MR. Cocaine-induced acute aortic dissection. J Emerg Med 2015;49:e87-e89.
Sznitman SR, Bretteville-Jensen AL. Public opinion and medical cannabis policies: Examining the role of underlying beliefs and national medical cannabis policies. Harm Reduct J 2015;12:46.
Wako E, LeDoux D, Mitsumori L, Aldea GS. The emerging epidemic of methamphetamine-induced aortic dissections. J Card Surg 2007;22:390-393.
Zvonarev V, Fatuki TA, Tregubenko P. The public health concerns of marijuana legalization: An overview of current trends. Cureus 2019;11:e5806
How to Cite
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).