Methamphetamine-Associated Congestive Heart Failure: Increasing Prevalence and Relationship of Clinical Outcomes to Continued Use or Abstinence

Cardiomyopathy in Patients With Acute Ischemic Stroke and Methamphetamine Use: Relevance for Cardioembolic Stroke and Outcome

BACKGROUND

Methamphetamine use has emerged as a major risk factor for cardiovascular and cerebrovascular disease in young adults. The aim of this study was to investigate a possible association of methamphetamine use with cardioembolic stroke.

METHODS AND RESULTS

We performed a retrospective study of patients with acute ischemic stroke admitted at our medical center between 2019 and 2022. All patients were screened for methamphetamine use and cardiomyopathy, defined as left ventricular ejection fraction ≤45%. Among 938 consecutive patients, 46 (4.9%) were identified as using methamphetamine. Compared with the nonmethamphetamine group (n=892), the methamphetamine group was significantly younger (52.8±9.6 versus 69.7±15.2 years; P<0.001), included more men (78.3% versus 52.8%; P<0.001), and had a significantly higher rate of cardiomyopathy (30.4% versus 14.0%; P<0.01). They were also less likely to have a history of atrial fibrillation (8.7% versus 33.4%; P<0.01) or hyperlipidemia (28.3% versus 51.7%; P<0.01). Compared with patients with cardiomyopathy without methamphetamine use, the patients with cardiomyopathy with methamphetamine use had significantly lower left ventricular ejection fraction (26.0±9.59% versus 32.47±9.52%; P<0.01) but better functional outcome at 3 months, likely attributable to significantly younger age and fewer comorbidities. In the logistic regression model of clinical variables, methamphetamine-associated cardiomyopathy was found to be significantly associated with cardioembolic stroke (odds ratio, 1.79 [95% CI, 1.04-3.06]; P<0.05).

CONCLUSIONS

We demonstrate that methamphetamine use is significantly associated with cardiomyopathy and cardioembolic stroke in young adults.

Vanillic acid alleviates methamphetamine-induced mitochondrial toxicity in cardiac mitochondria via antioxidant activity and inhibition of MPT Pore opening: an in-vitro study

BACKGROUND

Methamphetamine is widely abused in all parts of the world. It has been reported that short-term and long-term methamphetamine exposure could damage the dopaminergic system and induce cardiomyopathy and cardiotoxicity via mitochondrial dysfunction and oxidative stress. Vanillic acid (VA), a phenolic acid compound derived from plants, is known for its antioxidant and mitochondrial protection properties.

METHODS

In the current study we used VA for attenuating of Methamphetamine-induced mitochondrial toxicity in cardiac mitochondria. Isolated mitochondria obtained from rat heart were grouped as: control, methamphetamine (250 µM), VA (10, 50 and 100 µM) was cotreated with methamphetamine (250 µM) and VA (100 µM) alone. After 60 min, mitochondrial fraction including: succinate dehydrogenases (SDH) activity, mitochondrial membrane potential (MMP), mitochondrial swelling, mitochondrial glutathione (GSH), reactive oxygen species (ROS) and lipid peroxidation (LPO) were evaluated.

RESULTS

Methamphetamine exposure significantly disrupted mitochondrial function and induced ROS formation, lipid peroxidation, GSH depletion, MMP collapse and mitochondrial swelling, while VA significantly increased SDH activity as indicator of mitochondrial toxicity and dysfunction. VA also significantly decreased ROS formation, lipid peroxidation, mitochondrial swelling, MMP collapse and depletion of GSH in cardiac mitochondria in the presence of methamphetamine.

CONCLUSION

These findings suggested that VA is able to reduce methamphetamine-induced mitochondrial dysfunction and oxidative stress. Our results demonstrate that VA could potentially serve as a promising and accessible cardioprotective agent against methamphetamine-induced cardiotoxicity, via antioxidant and mitochondrial protection properties.

Methamphetamine-associated heart failure: a systematic review of observational studies

OBJECTIVE

To conduct a systematic review of observational studies on methamphetamine-associated heart failure (MethHF) .

METHODS

Six databases were searched for original publications on the topic. Title/abstract and included full-text publications were reviewed in duplicate. Data extraction and critical appraisal for risk of bias were performed in duplicate.

RESULTS

Twenty-one studies are included in the final analysis. Results could not be combined because of heterogeneity in study design, population, comparator, and outcome assessment. Overall risk of bias is moderate due to the presence of confounders, selection bias and poor matching; overall certainty in the evidence is very low. MethHF is increasing in prevalence, affects diverse racial/ethnic/sociodemographic groups with a male predominance; up to 44% have preserved left-ventricular ejection fraction. MethHF is associated with significant morbidity including worse heart failure symptoms compared with non-methamphetamine related heart failure. Female sex, methamphetamine abstinence and guideline-directed heart failure therapy are associated with improved outcomes. Chamber dimensions on echocardiography and fibrosis on biopsy predict the extent of recovery after abstinence.

CONCLUSIONS

The increasing prevalence of MethHF with associated morbidity underscores the urgent need for well designed prospective studies of people who use methamphetamine to accurately assess the epidemiology, clinical features, disease trajectory and outcomes of MethHF. Methamphetamine abstinence is an integral part of MethHF treatment; increased availability of effective non-pharmacological interventions for treatment of methamphetamine addiction is an essential first step. Availability of effective pharmacological treatment for methamphetamine addiction will further support MethHF treatment. Using harm reduction principles in an integrated addiction/HF treatment programme will bolster efforts to stem the increasing tide of MethHF.

Methamphetamine-associated cardiomyopathy: an addiction medicine perspective

Methamphetamine-associated cardiomyopathy (MaCM) is an increasingly recognised serious complication from methamphetamine (MA) use. It is characterised as the development of otherwise unexplained heart failure in the context of MA use. MaCM predominantly affects a young and vulnerable population with high morbidity and mortality. It is the second leading cause of mortality in patients with MA use disorder (MUD). Our understanding of MaCM pathogenesis is based on observational cohorts and autopsy studies. Currently, the treatment of MaCM is predicated on abstinence. Medical therapies offer some benefit to a minority of patients; however, without abstinence, medical therapies are often ineffective. Abstinence is difficult for most patients to achieve; all clinicians require an understanding of MaCM and how to educate patients on the risks of ongoing use. Where available, referral to addiction medicine specialists to assist with treatment of MUD is recommended. This review aims to: (i) explain the proposed pathologic mechanisms of MaCM; (ii) summarise recent recommendations of the screening and treatment of MaCM; and (iii) highlight the role of addiction medicine in the management of patient with MaCM.

Differentially Expressed Genes in Period 2-Overexpressing Mice Striatum May Underlie Their Lower Sensitivity to Methamphetamine Addiction-Like Behavior

Previous reports have demonstrated that genetic mechanisms greatly mediate responses to drugs of abuse, including methamphetamine (METH). The circadian gene Period 2 (Per2) has been previously associated with differential responses towards METH in mice. While the behavioral consequences of eliminating Per2 have been illustrated previously, Per2 overexpression has not yet been comprehensively described; although, Per2-overexpressing (Per2 OE) mice previously showed reduced sensitivity towards METH-induced addiction-like behaviors. To further elucidate this distinct behavior of Per2 OE mice to METH, we identified possible candidate biomarkers by determining striatal differentially expressed genes (DEGs) in both drug-naïve and METH-treated Per2 OE mice relative to wild-type (WT), through RNA sequencing. Of the several DEGs in drug naïve Per2 OE mice, we identified six genes that were altered after repeated METH treatment in WT mice, but not in Per2 OE mice. These results, validated by quantitative real-time polymerase chain reaction, could suggest that the identified DEGs might underlie the previously reported weaker METH-induced responses of Per2 OE mice compared to WT. Gene network analysis also revealed that Asic3, Hba-a1, and Rnf17 are possibly associated with Per2 through physical interactions and predicted correlations, and might potentially participate in addiction. Inhibiting the functional protein of Asic3 prior to METH administration resulted in the partial reduction of METH-induced conditioned place preference in WT mice, supporting a possible involvement of Asic3 in METH-induced reward. Although encouraging further investigations, our findings suggest that these DEGs, including Asic3, may play significant roles in the lower sensitivity of Per2 OE mice to METH.

A Comprehensive Approach to Managing Methamphetamine-Associated Cardiomyopathy

Methamphetamines are illicit drugs of the amphetamine-type stimulant class that have been increasing in popularity, availability, and purity in recent decades. As a result, rates of methamphetamine-associated cardiomyopathy (MAC) are rising globally. MAC is associated with high rates of sudden cardiac arrest, late presentation, and poor outcomes. This review discusses the medical management of MAC, including anticipated challenges specific to methamphetamine users. Not only are patients with MAC more likely to present at a younger age and with multisystem disease than patients with cardiomyopathy of other etiologies, but there may also be significant behavioral, psychosocial, financial, and system-based challenges to providing the best medical care. An individualized treatment plan that emphasizes methamphetamine abstinence as the foundation of therapy, as well as introducing optimal heart failure therapy and providing multidisciplinary support is likely to result in optimal outcomes. Given the potential reversibility of MAC, institution of guideline-directed heart failure therapy and patient support for adherence to therapy and abstinence from methamphetamines should be energetically pursued.

Systolic dysfunction in patients with methamphetamine use and heart failure with preserved ejection fraction

BACKGROUND

We aimed to evaluate for occult systolic dysfunction and the effect of methamphetamine cessation among patients with methamphetamine use (MU) and heart failure with preserved ejection fraction (HFpEF).

METHODS

A retrospective cohort of patients with HFpEF with serial echocardiograms was stratified by MU and evaluated using myocardial strain analysis on echocardiograms at baseline and 1 year to measure global longitudinal strain (GLS). Contemporaneous controls with an ICD diagnosis of HF within 3 days of an MU case were chosen.

RESULTS

Patients with MU (n = 31) were younger (49 ± 10 vs 59 ± 16 years, p < 0.01) and more frequently male (55% vs 26%, p = 0.04) than controls (n = 23). There was no baseline difference in ejection fraction (EF) (median 66% [IQR 58,71%] vs 62% [56,69%], p = 0.33) or GLS (-13.0% [-16.3,-10.9%] vs -14.8% [-16.0,-11.3%], p = 0.40). At one-year follow-up, MU cessation (n = 15) was associated with improvement in GLS (absolute change -4.4% [-6.5,-1.7%], p < 0.01), while no absolute change was observed with continued MU (n = 16) (0.74% [-1.2,-2.8%], p = 0.22) or controls without MU (-0.6% [-2.1,2.8%], p = 0.78). Of those with abnormal baseline GLS, normalization was observed in 46% with MU cessation, none with continued MU, and 5% of controls (p < 0.001). Among MU patients, improvement in GLS was associated with decreased HF admissions per year [HR 0.74 per 1% change in GLS, 95% CI 0.55,0.98, p = 0.04].

CONCLUSIONS

Patients with MU and HFpEF may have occult systolic dysfunction as demonstrated by abnormal GLS, and MU cessation at 1 year is associated with improvement in GLS and a reduction in risk of HF admissions.

Clinical and demographic factors associated with stimulant use disorder in a rural heart failure population

BACKGROUND

Heart failure is becoming increasingly common among patients under 50 years of age, particularly in African Americans and patients with stimulant use disorder. Yet the sources of these disparities remain poorly understood. This study identified key demographic and clinical factors associated with stimulant use disorder in a largely rural heart failure patient registry.

METHODS

Patient records reporting a diagnosis of heart failure between January 2008 and March 2020 were requested from West Virginia University Hospital Systems (n=37,872). Odds of stimulant use disorder were estimated by demographic group (age, race, sex), insurance carrier, and clinical comorbidities using logistic regression.

RESULTS

Multivariable regression analysis identified higher odds of stimulant use disorder among Black/African Americans (1.95 [1.32, 2.77]) and patients who report drinking one or more alcoholic drinks per week (2.23 [1.72, 2.88]). Lower odds of stimulant use disorder were identified among patients with hypertension (0.59 [0.47, 0.73]), or diabetes (0.65 [0.52, 0.81]).. Likewise, lower odds of stimulant use disorder were noted among females, patients older than 30 years of age and those not enrolled in Medicaid.

CONCLUSION

These results highlight the alarming extent to which Medicaid enrollees, Black/African Americans, people aged 18-24 and 25-44, or persons with a past alcohol use disorder diagnosis are associated with stimulant use disorder among heart failure populations living in largely rural areas. Additionally, they emphasize the need to develop policies and refine clinical care that affects this vulnerable population's prognoses.

Case series: Cariprazine for treatment of methamphetamine use disorder

BACKGROUND AND OBJECTIVES

Methamphetamine use is a major source of morbidity and mortality but has no reliably effective interventions. We identified cariprazine as an option for treatment of methamphetamine use disorder (MUD) and present two cases.

METHODS

Two patients with MUD and psychotic disorders were treated with cariprazine. Abstinence and cravings were assessed using urine drug screens and the Brief Substance Craving Scale, respectively.

RESULTS

Both patients reported global functional improvement, reduction in methamphetamine cravings and use with cariprazine, confirmed with negative urine drug screens.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Cariprazine's unique pharmacodynamic profile conveys potential efficacy for MUD. It would be a novel treatment that targets multiple psychiatric symptoms seen in MUD.

Characteristics of Methamphetamine-associated Cardiomyopathy and the Impact of Methamphetamine Use on Cardiac Dysfunction

Methamphetamine-associated cardiomyopathy (MACM) in an increasingly prevalent disease yet presenting clinical characteristics have not been well studied. We studied consecutive patients with MACM presenting between June 2018 and March 2020 who were interviewed for drug use and medical history. We retrospectively identified an age- and gender-matched cohort of Non-MACM (NMACM) patients and compared clinical characteristics. 140 patients (70 MACM and 70 NMACM) were studied. MACM patients were young (49.6 ± 10 years) and predominantly male (94%). Compared to NMACM, MACM patients were more likely to be Caucasian (21% vs 6%, p = 0.007) and homeless (47% vs 7%, p = 0.001). MACM was characterized by lower left ventricular ejection fraction (EF) (p <0.001) and greater LV end diastolic volume (LVEDV) (p = 0.024). Right ventricular (RV) dilation was present more often (p = s0.001) and was more often severe (p = 0.03). Among MACM cases, half of the cohort developed MACM within 5 years of starting MA (18% within 1 year). There was no apparent relationship between frequency or amount of MA used weekly with time until heart failure onset. Drug use patterns were not clearly related to the degree of LV structural change however there were more consistent, significant associations with RV and right atrial (RA) size parameters. In conclusion, patients with MACM have more severe myocardial impairment with lower EF, greater LVEDV and RV dilation. Drug use patterns do not clearly impact degree of LV structural changes by echocardiography however may be related to RV and RA size.

Methamphetamine-Associated Heart Failure Hospitalizations Across the United States: Geographic and Social Disparities

Background Although methamphetamine abuse is associated with the development of heart failure (HF), nationwide data on methamphetamine-associated HF (MethHF) hospitalizations are limited. This study evaluates nationwide HF hospitalizations associated with substance abuse to better understand MethHF prevalence trends and the clinical characteristics of those patients. Methods and Results This cross-sectional period-prevalence study used hospital discharge data from the National Inpatient Sample to identify adult primary HF hospitalizations with a secondary diagnosis of abuse of methamphetamines, cocaine, or alcohol in the United States from 2002 to 2014. All 2014 MethHF admissions were separated by regional census division to evaluate geographical distribution. Demographics, payer information, and clinical characteristics of MethHF hospitalizations were compared with all other HF hospitalizations. Total nationwide MethHF hospitalizations increased from 547 in 2002 to 6625 in 2014 with a predominance on the West Coast. Methamphetamine abuse was slightly more common among primary HF hospitalizations compared with all-cause hospitalizations (7.4 versus 6.4 per 1000; Cohen h=0.012; P<0.001). Among HF hospitalizations, patients with MethHF were younger (mean age, 48.9 versus 72.4 years; Cohen d=1.93; P<0.001), more likely to be on Medicaid (59.4% versus 8.8%; Cohen h=1.16; P<0.001) or uninsured (12.0% versus 2.6%; Cohen h=0.36; P<0.001), and more likely to present to urban hospitals (43.8% versus 28.3%; Cohen h=0.32; P<0.001) than patients with non-methamphetamine associated HF. Patients with MethHF had higher rates of psychiatric comorbidities and were more likely to leave the hospital against medical advice. Conclusions MethHF hospitalizations have significantly increased in the United States, particularly on the West Coast. Coordinated public health policies and systems of care are needed to address this rising epidemic.

Socioeconomic Burden of Rising Methamphetamine-Associated Heart Failure Hospitalizations in California From 2008 to 2018

BACKGROUND

Methamphetamine-associated cardiomyopathy/heart failure (MethHF) is an increasingly recognized disease entity in the context of a rising methamphetamine (meth) epidemic that most severely impacts the western United States. Using heart failure (HF) hospitalization data from the Office of Statewide Health Planning and Development, this study aimed to assess trend and disease burden of MethHF in California.

METHODS

Adult patients (≥18 years old) with HF as primary hospitalization diagnosis between 2008 and 2018 were included in this study. The association with Meth (MethHF) and those without (non-MethHF) were determined by meth-related International Classification of Diseases-based secondary diagnoses. Statistical significance of trends in age-adjusted rates of hospitalization per 100 000 adults were evaluated using nonparametric analysis.

RESULTS

Between 2008 and 2018, 1 033 076 HF hospitalizations were identified: 42 565 were MethHF (4.12%) and 990 511 (95.88%) were non-MethHF. Age-adjusted MethHF hospitalizations per 100 000 increased by 585% from 4.1 in 2008 to 28.1 in 2018, while non-MethHF hospitalizations decreased by 6.0% from 342.3 in 2008 to 321.6 in 2018. The rate of MethHF hospitalization increase more than doubled that of a negative control group with urinary tract infection and meth-related secondary diagnoses (7.82-fold versus 3.48-fold, P<0.001). Annual inflation-adjusted hospitalization charges because of MethHF increased by 840% from $41.5 million in 2008 to $390.2 million in 2018, as compared with an 82% increase for all HF hospitalization from $3.503 billion to $6.376 billion. Patients with MethHF were significantly younger (49.64±10.06 versus 72.20±14.97 years old, P<0.001), predominantly male (79.1% versus 52.4%, P<0.001), with lower Charlson Comorbidity Index, yet they had longer length of stay, more hospitalizations per patient, and more procedures performed during their stays.

CONCLUSIONS

MethHF hospitalizations increased sharply during the study period and contributed significantly to the HF hospitalization burden in California. This emerging HF phenotype, which engenders considerable financial and societal costs, calls for an urgent and concerted public health response to contain its spread.

Methamphetamine Use is Associated with Increased Surgical Site Infections after Trauma Laparotomy

BACKGROUND

Methamphetamine (METH) use causes significant vasoconstriction, which can be severe enough to cause bowel ischemia. Methamphetamines have also been shown to alter the immune response. These effects could predispose METH users to poor wound healing, increased infections, and other post-operative complications. We hypothesized that METH users would have longer length of stay and higher rates of complications compared to non-METH users.

METHODS

The trauma registry for our urban Level 1 trauma center was searched for patients that received an exploratory laparotomy from 2016 to 2019. A total 204 patients met criteria and 52 (25.5%) were METH positive. Length of stay (LOS), ventilator days, abbreviated injury scale (AIS), and wound class were compared using nonparametric statistics. Age and injury severity score (ISS) were compared using a Student's t-test. A Chi Square or Fisher's Exact test was used to compare sex, mechanism of injury, and rates of infectious complications.

RESULTS

Methamphetamine-positive patients had a significantly higher rate of surgical site infections (7.4% versus 0%, P = 0.001). Patients that developed surgical site infection had equivalent rates of smoking and diabetes, as well as equivalent abdominal AIS and wound class compared to those who did not develop surgical site infection. Hospital and ICU LOS, ventilator days, ISS, and mortality were equivalent between METH positive and negative patients. Rates of other infectious complications were the same between groups.

CONCLUSIONS

Methamphetamine use is associated with an increased rate of surgical site infection after trauma laparotomy. Other serious complications and mortality were not affected by METH use.

Methamphetamine in Orthopaedics: Considerations of an At-Risk Population

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Methamphetamine use by orthopaedic trauma patients has risen to epidemic proportions.

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Perioperative methamphetamine use by orthopaedic trauma patients requires physicians to consider both medical and psychosocial factors during treatment.

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Behavioral and psychosocial effects of methamphetamine use present barriers to care.

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Patients who use methamphetamine face elevated rates of complications.

Psychosocial Syndemics and Multimorbidity in Patients with Heart Failure †

Heart failure (HF) is a common cause of hospitalization and mortality in older adults. HF is almost always embedded within a larger pattern of multimorbidity, yet many studies exclude patients with complex psychiatric and medical comorbidities or cognitive impairment. This has left significant gaps in research on the problems and treatment of patients with HF. In addition, HF is only one of multiple challenges facing patients with multimorbidity, stressful socioeconomic circumstances, and psychosocial problems. The purpose of this study is to identify combinations of comorbidities and health disparities that may affect HF outcomes and require different mixtures of medical, psychological, and social services to address. The syndemics framework has yielded important insights into other disorders such as HIV/AIDS, but it has not been applied to the complex psychosocial problems of patients with HF. The multimorbidity framework is an alternative approach for investigating the effects of multiple comorbidities on health outcomes. The specific aims are: (1) to determine the coprevalence of psychiatric and medical comorbidities in patients with HF (n = 535); (2) to determine whether coprevalent comorbidities have synergistic effects on readmissions, mortality, self-care, and global health; (3) to identify vulnerable subpopulations of patients with HF who have high coprevalences of syndemic comorbidities; (4) to determine the extent to which syndemic comorbidities explain adverse HF outcomes in vulnerable subgroups of patients with HF; and (5) to determine the effects of multimorbidity on readmissions, mortality, self-care, and global health.

The rising tide of methamphetamine use in elderly trauma patients

BACKGROUND

Methamphetamine (METH) is associated with an elevated risk of injury and the outcomes in the elderly remain unclear. We analyzed METH's impact in elderly trauma patients.

METHODS

Retrospective analysis (2009-2018) of trauma patients at a Level I trauma center. Elderly patients were defined as age ≥55. Substance use was identified by blood alcohol test and urine drug screen. Cox proportional hazard model was used to assess patient and injury characteristics with mortality.

RESULTS

Of 15,770 patient encounters with substance use testing, 5278 (34%) were elderly. Elderly METH use quadrupled over time (2%-8%; p < 0.01). Elderly METH + patients were more likely to require surgical intervention (35% vs. 17%), mechanical ventilation (15% vs. 7%), and a longer hospitalization (6.5 vs. 3.6 days) compared with elderly substance negative. Multivariate analysis showed increasing age, ventilator use, and injury severity were associated with mortality (ps < 0.01); METH was not related to mortality.

CONCLUSION

Substance use in elderly trauma patients increased significantly. METH use in elderly trauma patients is a risk factor for significantly greater resource utilization.

Characteristics, trends, outcomes, and costs of stimulant-related acute heart failure hospitalizations in the United States

BACKGROUND

Heart failure (HF) hospitalizations remains a significant burden on the health care system. Stimulants including cocaine, amphetamine and its derivatives are amongst the most used illegal substances in the United States. The information regarding stimulant-related HF hospitalizations is scarce. We sought to evaluate the characteristics and trends of stimulant-related HF hospitalizations in the United States and their associated outcomes and resource utilization.

METHODS

Using the National Inpatient Sample (NIS), we identified patients with a primary diagnosis of HF hospitalization. These hospitalizations were further divided into those with and without a concomitant diagnosis of stimulant (cocaine or amphetamine) dependence or abuse. Survey specific techniques were employed to compare trends in baseline characteristics, complications, procedures, outcomes and resource utilization between the two cohorts.

RESULTS

We identified 9,932,753 hospitalizations (weighted) with a primary diagnosis of heart failure, of those 138,438 (1.39%) had a diagnosis of active stimulant use. The proportion of stimulant-related HF hospitalization is on the rise (1.1% to 1.9%). Stimulant-related HF hospitalization was highest amongst age group 30-39 years and 7.9% of HF hospitalizations in this age group were due to stimulant use. The proportion of stimulant-related HF hospitalization for the White and Hispanic race has doubled from 2008 to 2017. Stimulant-related HF hospitalization is associated with increased incidence of in-hospital complications like cardiogenic shock, acute kidney injury and ventricular tachycardia. These patients have more than 7-fold higher discharge against medical advice.

CONCLUSIONS

Stimulant-related HF hospitalizations have been increasing. It is associate with significant morbidity burden and health care utilization.

Clinical and echocardiographic outcomes in heart failure associated with methamphetamine use and cessation

OBJECTIVE

Methamphetamine use is associated with systolic dysfunction, pulmonary arterial hypertension and may also be associated with diastolic dysfunction. The impact of methamphetamine cessation on methamphetamine-associated heart failure (MethHF) remains poorly characterised. We aimed to longitudinally characterise methamphetamine-associated heart failure patients with reduced (METHrEF) and preserved (METHpEF) left ventricular ejection fraction (EF), and evaluate the relationship between methamphetamine cessation and clinical outcomes.

METHODS

We performed a retrospective cohort study, and reviewed medical records of patients with METHrEF, METHpEF and heart failure controls without methamphetamine use. Echocardiographic variables were recorded for up to 12 months, with clinical follow-up extending to 24 months.

RESULTS

Among METHrEF patients (n=28, mean age 51±9 years, 82.1% male), cessation was associated with improvement in EF (+10.6±13.1%, p=0.009) and fewer heart failure admissions per year compared with continued use (median 0.0, IQR 0.0-1.0 vs median 2.0, IQR 1.0-3.0, p=0.039). METHpEF patients (n=28, mean age 50±8 years, 60.7% male) had higher baseline right ventricular systolic pressure (median 53.44, IQR 43.70-84.00 vs median 36.64, IQR 29.44-45.95, p=0.011), and lower lateral E/E' ratio (8.1±3.6 vs 11.2±4., p<0.01) compared with controls (n=32). Significant improvements in echocardiographic parameters and clinical outcomes were not observed following cessation in this group.

CONCLUSIONS

METHrEF patients who cease methamphetamine use have significant improvement in left ventricular systolic function and fewer heart failure admissions, suggesting that METHrEF may be reversible. Echocardiographic parameters suggest that some patients with METHpEF may have pulmonary hypertension in the absence of overt signs of left ventricular diastolic dysfunction, but additional study is needed to characterise this patient cohort.

Amphetamine-type stimulant use among patients admitted to the emergency department behavioural assessment unit: Screening and referral outcomes

Amphetamine-type stimulant use, including methamphetamine, amphetamine, and 3,4-methylenedioxymethamphetamine, is associated with a range of behavioural symptoms. Screening for amphetamine-type stimulant use among people presenting to the emergency department with behavioural disturbance and referral to treatment has not been evaluated. The objective of this study was to determine the prevalence of amphetamine-type stimulant use among patients admitted to a behavioural assessment unit and report referral outcomes. A prospective observational design was used. Individuals who tested positive or self-reported amphetamine-type stimulant use were referred to the alcohol and other drug clinician. We measured the prevalence of amphetamine-type stimulant use in saliva and by self-report along with rates of referral. The setting was a behavioural assessment unit located within an Australian emergency department. Admitted adults were enrolled from July to December 2017. Those who tested positive or self-reported amphetamine-type stimulant use were provided with harm reduction advice and offered referral. Four hundred and seventy-two tests were performed. Fifteen were excluded due to invalid results or redundant enrolment. Of the 457 individuals, 59% were male, with a mean age of 35 years (SD 13). Fifty-three (11.6%, 95% CI: 8.9-15.0) tested positive for amphetamine-type stimulants. Of those with a negative test, 44 (9.6%, 95% CI: 7.3-12.7) self-reported amphetamine-type stimulant use in the previous 24 hours. The prevalence of amphetamine-type stimulant use was 21.2% (95% CI: 17.7-25.2). Most accepted referral to the alcohol and other drug clinician (85.6%, 95% CI 77.2-91.2). The emergency visit represents a window of opportunity for screening for amphetamine-type stimulant use and initiating referrals.

The Cardiac Conduction and Contractility Complications of Methamphetamine Use and the Relationship to Psychiatric Comorbidity: A Systematic Review

Background:

Methamphetamine has the potential to produce more severe short and long term effects than typical amphetamines due to the drug’s increased purity. The cardiovascular consequences compromise a large proportion of the drug’s mortality. Previous reviews have not examined these complications in relation to psychiatric patients who have high rates of substance use and physical comorbidity.

Methods:

Ovid Medline, Embase, Emcare, PsycINFO, CINAHL, and Cochrane were systematically searched in English until November 2017. Data were coded according to study design, sample size, demographics, medical and psychiatric comorbidity, electrocardiograph abnormalities, echocardiograph parameters, illness severity, treatment, and outcome on follow up.

Results:

The 11 included studies were predominantly case series conducted in the USA. Males were more likely to use methamphetamine and be associated with global systolic dysfunction. The mean age was lower for those with methamphetamine-related cardiovascular complications. QTc interval prolongation was the most frequent electrocardiograph abnormality. Continued methamphetamine use was associated with persistently impaired ventricular function, whilst discontinuation led to remodeling and improved ejection fraction. Only one study referenced psychiatric comorbidity or dual diagnosis.

Conclusion:

This review describes the range of variables related to methamphetamine associated arrhythmias and cardiomyopathies. Early detection of methamphetamine use and the subsequent cardiac complications is important, especially in a psychiatric cohort where physical illness is more commonly neglected. The monitoring of electrocardiographs in methamphetamine users is also crucial. Future research is needed to allow for appropriate recommendations in managing the harmful impacts of methamphetamine use in this population.

The emergence of cardiac changes following the self-administration of methamphetamine

BACKGROUND

Clinical observations suggest an association between methamphetamine (METH) use and cardiovascular disease, but preclinical studies are lacking. The purpose of the current study was to explore changes in left ventricular function as a potential precursor to cardiovascular disease in a rodent model of METH use.

METHODS

Male rats were allowed to self-administer either METH or saline for 9 d. On the day following the 4th and 9th self-administration sessions, an echocardiogram was performed to assess left-ventricular parameters under basal conditions and following a low-dose of METH (1 mg/kg).

RESULTS

A low challenge dose of METH resulted in subtle but statistically significant changes in cardiac function during the echocardiogram in both the METH and saline self-administering groups. Further, differences in left-ventricular parameters such as stroke volume and heart rate were observed between METH and saline groups following the 9th self-administration session. Finally, supervised machine learning correctly predicted the self-administration group assignment (saline or METH) using cardiac parameters following the 9th self-administration session.

CONCLUSIONS

The findings of the current study suggest the heart, specifically the left ventricle, is sensitive to METH. Overall, these findings and emerging clinical observations highlight the need for research to investigate the effects of METH use on the heart.

Clinical Characteristics and Management of Methamphetamine-Associated Cardiomyopathy: State-of-the-Art Review

Methamphetamine‐associated cardiomyopathy (MACM) is an increasingly recognized disease entity in the context of a rapidly spreading methamphetamine epidemic. MACM may afflict individuals with a wide range of ages and socioeconomic backgrounds. Presentations can vary greatly and may involve several complications unique to the disease. Given the public health significance of this disease, there is a relative dearth of consensus material to guide clinicians in understanding, diagnosing, and managing MACM. This review therefore aims to: (1) describe pathologic mechanisms of methamphetamine as they pertain to the development, progression, and prognosis of MACM, and the potential to recover cardiac function; (2) summarize existing data from epidemiologic studies and case series in an effort to improve recognition and diagnosis of the disease; (3) guide short‐ and long‐term management of MACM with special attention to expected or potential sequelae of the disease; and (4) highlight pivotal unanswered questions in need of urgent investigation from a public health perspective.

TBHQ Attenuates Neurotoxicity Induced by Methamphetamine in the VTA through the Nrf2/HO-1 and PI3K/AKT Signaling Pathways

Methamphetamine (METH) leads to nervous system toxicity. Long-term exposure to METH results in damage to dopamine neurons in the ventral tegmental area (VTA), and depression-like behavior is a clinical symptom of this toxicity. The current study was designed to investigate whether the antioxidant tertiary butylhydroquinone (TBHQ) can alleviate neurotoxicity through both antioxidative stress and antiapoptotic signaling pathways in the VTA. Rats were randomly divided into a control group, a METH-treated group (METH group), and a METH+TBHQ-treated group (METH+TBHQ group). Intraperitoneal injections of METH at a dose of 10 mg/kg were administered to the rats in the METH and METH+TBHQ groups for one week, and METH was then administered at a dose that increased by 1 mg/kg per week until the sixth week, when the daily dosage reached 15 mg/kg. The rats in the METH+TBHQ group received 12.5 mg/kg TBHQ intragastrically. Chronic exposure to METH resulted in increased immobility times in the forced swimming test (FST) and tail suspension test (TST) and led to depression-like behavior. The production of reactive oxygen species (ROS) and apoptosis levels were increased in the VTA of animals in the METH-treated group. METH downregulated Nrf2, HO-1, PI3K, and AKT, key factors of oxidative stress, and the apoptosis signaling pathway. Moreover, METH increased the caspase-3 immunocontent. These changes were reversed by treatment with the antioxidant TBHQ. The results indicate that TBHQ can enhance Nrf2-induced antioxidative stress and PI3K-induced antiapoptotic effects, which can alleviate METH-induced ROS and apoptosis, and that the crosstalk between Nrf2 and PI3K/AKT is likely the key factor involved in the protective effect of TBHQ against METH-induced chronic nervous system toxicity.

Delayed cardiomyopathy and cardiogenic shock due to intravenous methamphetamine use requiring hemodynamic support with veno-arterial extracorporeal membrane oxygenation

Cardiovascular disease is the leading cause of mortality in chronic methamphetamine users. We present the case of a 29-year-old man, a prior heroin user, who presented following first-time use of intravenous methamphetamine, with delayed development of cardiomyopathy and severe cardiogenic shock, treated with veno-arterial extracorporeal membrane oxygenation (VA ECMO), and subsequent recovery. His initial chief complaint was shortness of breath, a common presentation to the emergency department. However, this case presentation is unique in three aspects: (1) a delayed presentation, (2) methamphetamine was administered intravenously as opposed to the common methods of being snorted or smoked, (3) and the effects were seen after first-time usage as compared to in a chronic user. This unique presentation can bring awareness to an uncommon etiology of shortness of breath due to intravenous methamphetamine usage.

The Impact of Substance Abuse on Heart Failure Hospitalizations

BACKGROUND

The burden of substance abuse among patients with heart failure and its association with subsequent emergency department visits and hospital admissions are poorly characterized.

METHODS

We evaluated the medical records of patients with a diagnosis of heart failure treated at the University of California-San Diego from 2005 to 2016. We identified substance abuse via diagnosis codes or urine drug screens. We used Poisson regression to evaluate the incidence rate ratios (IRR) of substance abuse for emergency department visits or hospitalizations with a primary diagnosis of heart failure, adjusted for age, sex, race, medical insurance status, and medical diagnoses.

RESULTS

We identified 11,268 patients with heart failure and 15,909 hospital encounters for heart failure over 49,712 person-years of follow-up. Substance abuse was diagnosed in 15.2% of patients. Disorders such as methamphetamine abuse (prevalence 5.2%, IRR 1.96, 95% confidence interval [CI] 1.85-2.07), opioid use and abuse (8.2%, IRR 1.54, 95% CI 1.47-1.61), and alcohol abuse (4.5%, IRR 1.51, 95% CI 1.42-1.60) were associated with a greater number of hospital encounters for heart failure, with associations that were comparable to diagnoses such as atrial fibrillation (37%, IRR 1.78, 95% CI 1.73-1.84), ischemic heart disease (24%, IRR 1.67, 95% CI 1.62-1.73), and chronic kidney disease (26%, IRR 1.57, 95% CI 1.51-1.62).

CONCLUSIONS

Although less prevalent than common medical comorbidities in patients with heart failure, substance-abuse disorders are significant sources of morbidity that are independently associated with emergency department visits and hospitalizations for heart failure. Greater recognition and treatment of substance abuse may improve outcomes among patients with heart failure.

Methamphetamine-related cardiovascular diseases

Aims

Abuse of crystal methamphetamine (MA) poses a growing problem for health services worldwide. This review summarizes the current literature on the effects of MA on the cardiovascular system.

Methods and results

This article is a presentation of a case report and review of the current literature. In Europe, especially the eastern countries and the eastern states of Germany are affected. MA increases the concentration of catecholamines in the synaptic gap leading to euphoria, alertness, and hunger suppression as well as psychiatric and gastrointestinal complications. MA consumption is associated with hypertension, acute and chronic myocardial toxicity, stroke, coronary artery disease, and sudden cardiac death. Although many aspects of the underlying pathophysiology remain unknown, catecholamine‐mediated pathologies appear to play an important role. The duration of MA consumption is the most important determinant for the prognosis.

Conclusions

Awareness is needed as cardiac complications are important causes of morbidity and mortality in patients with MA consumption. Drug abstinence is the mainstay of therapy, cardiac and other complications should be treated according to the respective guidelines. Incompliance to therapy and frequent relapses are the main challenges for successful treatment. Further research is required to improve the understanding of this rapidly increasing cardiomyopathy.

Comparison of Clinical Characteristics and Outcomes of Patients With Reversible Versus Persistent Methamphetamine-Associated Cardiomyopathy

Anecdotal cases of reversible methamphetamine-associated cardiomyopathy (rMAC) have been reported, but not well understood. This study sought to determine the clinical characteristics, outcomes and predictors of reversibility among patients with rMAC as compared with patients with persistent MAC (pMAC). We retrospectively studied adult MAC patients with left ventricular ejection fraction (LVEF) ≤40% at a single center between 2004 and 2018. rMAC was defined as increase in LVEF by ≥20 points or to ≥50%. Those with persistent LVEF ≤40% constituted the pMAC group. 357 MAC cases were identified: 250 patients had pMAC and 107 had rMAC. After a median follow-up of 45 months (interquartile range 27 to 70), LVEF increased by 28.3 ± 6.9% in rMAC (p <0.001), whereas it was unchanged in pMAC (Δ: -0.5 ± 8.7%, p = 0.350). Heart failure hospitalizations and New York Heart Association Class III/IV heart failure were both significantly reduced for rMAC than the pMAC group. All-cause mortality was 21.6% overall, 28% in pMAC and 6.5% in the rMAC group (p <0.001). Kaplan-Meier survival curves demonstrated significantly higher cumulative survival for rMAC (Log Rank p <0.001). Multivariable logistic regression identified MA cessation (odds ratio/OR: 4.23, 95% confidence interval/CI: 2.47 to 7.38, p <0.001) and baseline right ventricular end systolic area (OR: 0.92, 95% CI: 0.87 to 0.97, p = 0.001) as strongly predictive of MAC reversal. In conclusion, MAC reversal is not uncommon and is associated with significant clinical improvement including reduced mortality. It can be facilitated by MA cessation when the cardiac chambers, especially the right ventricle, are not severely dilated.

Cerebrovascular and cardiovascular diseases caused by drugs of abuse

Drugs such as stimulants, sedatives, sleeping pills, and narcotics are associated with drug abuse and are therefore regulated by law. Physical dependence on these drugs is sometimes difficult to control despite an awareness of the problems they cause in daily life and the harm they can cause to the body. Drug dependence is a social problem worldwide, and the physical implications are serious. Many of these drugs cause cerebrovascular and cardiovascular diseases, which often require emergency medical treatment. Differential diagnosis is essential because of the likelihood of life-threatening events, especially among young people who exhibit cerebrovascular and cardiovascular diseases without any of the typical risk factors. Drugs of abuse, especially stimulants, induce a hyperadrenergic state that evokes vasoconstriction and tachycardia, as well as subsequent ischemic and hemorrhagic stroke, acute coronary syndrome, arrhythmias, and aortic dissection. Chronic drug abuse can also cause cardiac hypertrophy and left ventricular dysfunction. As a treatment for these conditions, sedative drugs can be effective but the use of vasodilators may also be required. There are concerns that the use of both alpha- and beta-adrenergic receptor blockers may cause tachycardia and increased blood pressure. Therefore, careful differential diagnosis and selection of therapeutic agents is required.

Characteristics and Outcomes of Methamphetamine Abuse Among Veterans With Heart Failure

Methamphetamine is one of the most commonly abused illicit substances worldwide. Chronic methamphetamine abuse (MA) is associated with the development of a dilated cardiomyopathy. MA in patients with heart failure (MethHF) is increasingly reported yet poorly characterized. This was a retrospective cohort study of veterans treated at the VA Medical Center in San Diego between 2005 and 2015 with a diagnosis of HF and a history of MA. The incidence of MA each year was calculated, and clinical characteristics and outcomes of veterans with HF with and without MA were compared. Among 9,491 veterans with HF, 429 were identified as having a history of MA. Between 2006 and 2015, the incidence of MA in veterans with HF doubled from 3.44% to 6.70%. Of the 429 identified, 106 veterans had a hospitalization for HF and they were compared with veterans with HF without evidence of MA (HF). Compared with veterans with HF, veterans with MethHF were significantly younger (60.7 ± 7.3 vs 71.6 ± 11.6 years, p <0.001), with more frequent co-morbid post-traumatic stress disorder (16.8% vs 4.4%, p = 0.006), depression (28.7% vs 11.0%, p = 0.002), homelessness (27.9% vs 8.9%, p = 0.001), and unemployment (55.8% vs 30.0%, p <0.001). Despite their younger age, veterans with MethHF had high rates of HF readmission or emergency room visit (49% vs 38% in MethHF vs HF, p = 0.34) and mortality at 6 months (27% vs 38% in MethHF vs HF, p = 0.10) compared with HF. In conclusion, MA in veterans with HF is on the rise. Certain demographic and clinical characteristics of veterans with MethHF may contribute to their poor outcomes.

National Rate of Tobacco and Substance Use Disorders Among Hospitalized Heart Failure Patients

BACKGROUND

Several cardiotoxic substances impact heart failure incidence. The burden of comorbid tobacco or substance use disorders among heart failure patients is under-characterized. We describe the burden of tobacco and substance use disorders among hospitalized heart failure patients in the United States.

METHODS

We calculated the proportion of primary heart failure hospitalizations in the 2014 National Inpatient Sample with tobacco or substance use disorders accounting for demographic factors.

RESULTS

Of 989,080 heart failure hospitalizations, 15.5% (n = 152,965) had documented tobacco (n = 119,285, 12.1%) or substance (n = 61,510, 6.2%) use disorder. Female sex was associated with lower rates of tobacco (odds ratio [OR] 0.72; 95% confidence interval [CI], 0.70-0.74) and substance (OR 0.37; 95% CI, 0.36-0.39) use disorder. Tobacco and substance use disorder rates were highest for hospitalizations <55years of age. Native American race was associated with increased risk of alcohol use disorder (OR 1.67; 95% CI, 1.27-2.20) and black race with alcohol (OR 1.09; 95% CI, 1.02-1.16) or drug (OR 1.63; 95% CI, 1.53-1.74) use disorder. Medicaid insurance or income in the lowest quartile were associated with increased risk of tobacco and substance use disorders.

CONCLUSIONS

Tobacco and substance use disorders affect vulnerable heart failure populations, including those of male sex, younger age, lower socioeconomic status, and racial/ethnic minorities. Enhanced screening for tobacco and substance use disorders in hospitalized heart failure patients may reveal opportunities for treatment and secondary prevention.

Hypertensive heart disease associated with methamphetamine abuse

In Japan, methamphetamine accounts for the majority of illicit drug use and dependence is becoming a critical issue. Methamphetamine abuse induces cardiovascular complications, such as cardiomyopathy and heart failure. However, methamphetamine-associated cardiovascular complications are not common in Japan. We report the case of a young patient with hypertensive heart disease associated with habitual methamphetamine abuse. A 37-year-old man was admitted with congestive heart failure. He was a habitual methamphetamine abuser and developed chronic hypertension after he started methamphetamine abuse. His echocardiogram demonstrated left ventricular concentric hypertrophy with diffuse hypokinesis. An endomyocardial biopsy revealed histological evidence of a hypertensive heart. This case shows that habitual methamphetamine use may cause hypertensive heart disease because of chronic hypertension. <Learning objective: Methamphetamine-associated cardiomyopathy and congestive heart failure are uncommon in Japan. However, habitual methamphetamine abuse can be a potential cause of hypertensive heart disease due to chronic hypertension and congestive heart failure associated with hypertrophy.>.

Evaluation of Amphetamine-Related Hospitalizations and Associated Clinical Outcomes and Costs in the United States

IMPORTANCE

Despite indications of increasing amphetamine availability and psychostimulant deaths in the United States, evidence across data sources is mixed, and data on amphetamine-related hospitalizations are lacking.

OBJECTIVE

To clarify trends in amphetamine-related hospitalizations and their clinical outcomes and costs in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This repeated, cross-sectional study used hospital discharge data from the Healthcare Cost and Utilization Project National Inpatient Sample. The nationally representative sample included US adults (n = 1 292 300) who had amphetamine-related hospitalizations between January 1, 2003, and December 31, 2015. Multivariable logistic and Poisson regression models were used to examine in-hospital mortality and length of stay. Analysis of these data was conducted from November 2017 to August 2018.

EXPOSURE

Amphetamine dependence or abuse or amphetamine poisoning.

MAIN OUTCOMES AND MEASURES

Annual hospitalizations, in-hospital mortality, length of stay, transfer to another facility, and costs.

RESULTS

Over the 2003 to 2015 study period, there were 1 292 300 weighted amphetamine-related hospitalizations. Of this population, 541 199 (41.9%) were female and 749 392 (58.1%) were male, with a mean age of 37.5 years (95% CI, 37.4-37.7 years). Amphetamine-related hospitalizations, compared with other hospitalizations, were associated with age younger than 65 years (98.0% vs 58.0%; P < .001), male sex (60.3% [95% CI, 59.7%-60.8%] vs 41.1% [95% CI, 40.9%-41.3%]), Medicaid coverage (51.2% [95% CI, 49.8%-52.7%] vs 17.8% [95% CI, 17.5%-18.1%]), and residence in the western United States (58.5% [95% CI, 55.9%-61.0%] vs 18.9% [95% CI, 18.0%-19.8%]). Amphetamine-related hospitalizations declined between 2005 and 2008, and then increased from 55 447 hospitalizations (95% CI, 44 936-65 959) in 2008 to 206 180 hospitalizations (95% CI, 95% CI, 189 188-223 172) in 2015. Amphetamine-related hospitalizations increased to a greater degree than hospitalizations associated with other substances. Adjusted mean length of stay (5.9 [95% CI, 5.8-6.0] vs 4.7 [95% CI, 4.7-4.8] days; P < .001), transfer to another facility (26.0% [95% CI, 25.3%-26.8%] vs 18.5% [95% CI, 18.3%-18.6%]; P < .001), and mean in-hospital mortality (28.3 [95% CI, 26.2-30.4] vs 21.9 [95% CI, 21.6-22.1] deaths per 1000 hospitalizations; P < .001) were higher for amphetamine-related than other hospitalizations. Annual hospital costs related to amphetamines increased from $436 million (95% CI, $312 million-$559 million) in 2003 to $2.17 billion (95% CI, $1.95 billion-$2.39 billion) by 2015.

CONCLUSIONS AND RELEVANCE

Given that amphetamine-related hospitalizations and costs substantially increased between 2003 and 2015, pharmacologic and nonpharmacologic therapies for amphetamine use disorders and a coordinated public health response are needed to curb these rising rates.

Exposure to Amphetamines Leads to Development of Amphetamine Type Stimulants Associated Cardiomyopathy (ATSAC)

With rapidly rising prevalence of exposure to Amphetamine Type Stimulants (ATS), novel insights into cardiotoxic effects of this substance are being presented in the literature and remarkably ATS Associated Cardiomyopathy (ATSAC) is emerging as a novel cardiovascular condition with its distinctive pathogenesis, risk factors, clinical features and prognosis. A comprehensive systematic review was performed to explore and analyze the current evidence on the association between ATS exposure and development of cardiomyopathy, biological mechanisms involved in pathogenesis of ATSAC, risk factors, clinical features and course of patients with ATSAC. Several animal studies, case reports, case series and case-control studies support the association between ATS exposure and ATSAC. Oxidative stress, accelerated apoptosis, increased p53 activity, cardiomyocyte necrosis, perfusion defects, fatty acid toxicity, altered gene expression, abnormal cardiac protein synthesis and function in addition to defects in intracellular calcium hemostasis present themselves as likely mechanisms of cardiotoxicity in ATSAC. Majority of patients with ATSAC were found to be male, young and presented late with severe dilated cardiomyopathy. Female ATS users predominantly develop Takotsubo type of ATSAC and in particular its atypical basal variant. Overall, cessation of ATS exposure seems to be associated with some degree of reversibility and recovery in ATSAC sufferers.

Outcomes and mortality in parturient and non-parturient patients with peripartum cardiomyopathy: A national readmission database study

BACKGROUND

Peripartum cardiomyopathy (PPCM) affects young females and mortality occurs after the peripartum period. Hospital readmissions for patients discharged with PPCM are poorly understood. The aim of this study was to evaluate differences in readmission rates, risk factors, and mortality in women with PPCM.

METHODS

We conducted a retrospective cohort analysis using the Healthcare Cost and Utilization Project 2013 National Readmissions Database. From the database, we selected patients with PPCM to include patients discharged between January and November 2013. Readmission rate, mortality rate and risk factors were analyzed. In our cohort of 3800 patients, we found a readmission rate of 15.1% and a mortality rate of 1.6%. Comorbidities associated with readmission were pulmonary hypertension, obesity, renal failure, and drug abuse. Mortality on initial admission was associated with coagulation disorders and respiratory failure. Women who delivered on initial admission had a statistically lower rate of readmission than women who did not deliver on initial admission.

CONCLUSIONS

In a large retrospective nationwide analysis of PPCM patients, we found associated conditions that may help predict which patients will have a higher risk for readmission and mortality.

TBHQ Alleviated Endoplasmic Reticulum Stress-Apoptosis and Oxidative Stress by PERK-Nrf2 Crosstalk in Methamphetamine-Induced Chronic Pulmonary Toxicity

Methamphetamine (MA) leads to cardiac and pulmonary toxicity expressed as increases in inflammatory responses and oxidative stress. However, some interactions may exist between oxidative stress and endoplasmic reticulum stress (ERS). The current study is designed to investigate if both oxidative stress and ERS are involved in MA-induced chronic pulmonary toxicity and if antioxidant tertiary butylhydroquinone (TBHQ) alleviated ERS-apoptosis and oxidative stress by PERK-Nrf2 crosstalk. In this study, the rats were randomly divided into control group, MA-treated group (MA), and MA plus TBHQ-treated group (MA + TBHQ). Chronic exposure to MA resulted in slower growth of weight and pulmonary toxicity of the rats by increasing the pulmonary arterial pressure, promoting the hypertrophy of right ventricle and the remodeling of pulmonary arteries. MA inhibited the Nrf2-mediated antioxidative stress by downregulation of Nrf2, GCS, and HO-1 and upregulation of SOD2. MA increased GRP78 to induce ERS. Overexpression and phosphorylation of PERK rapidly phosphorylated eIF2α, increased ATF4, CHOP, bax, caspase 3, and caspase 12, and decreased bcl-2. These changes can be reversed by antioxidant TBHQ through upregulating expression of Nrf2. The above results indicated that TBHQ can alleviate MA-induced oxidative stress which can accelerate ERS to initiate PERK-dependent apoptosis and that PERK/Nrf2 is likely to be the key crosstalk between oxidative stress and ERS in MA-induced chronic pulmonary toxicity.