The Cardiac Complications of Methamphetamines

Determination of Methamphetamine by High-Performance Liquid Chromatography in Odor-Adsorbent Material Used for Training Drug-Detection Animals

The objective of the present report was to develop and validate a simple, sensitive, and selective analytical method for the determination of methamphetamine in an odor-adsorbent material (gauze) which was used to improve and standardize the training method used for drug-detection animals. High-performance liquid chromatography (HPLC) was performed using a Spherisorb ODS2 C18 column (200 mm × 4.6 mm, 5 μm), with a mobile phase consisting of a 0.25% methanol/triethylamine aqueous solution (V:V = 20:80), the pH of which was adjusted to 3.1 using glacial acetic acid, at a flow rate of 1.0 mL/min. The column temperature was 25 °C, and the detection of the analytes was performed at a wavelength of 260 nm. Methamphetamine showed good linearity (R2 = 0.9999) in the range of 4.2~83.2 mg/mL. The stability of the test material was good over 24 h. The precision of the method was good, with an average spiked recovery of 86.2% and an RSD of 2.9%. The methamphetamine content in the gauze sample was determined to be 7.8 ± 2.2 μg/sample. A high-performance liquid chromatography (HPLC) method was optimized and validated for the determination of methamphetamine in adsorbent materials (gauze). Validation data in terms of specificity, linearity, the limit of detection and the limit of quantification, reproducibility, precision, stability, and recovery indicated that the method is suitable for the routine analysis of methamphetamine in adsorbent materials (gauze) and provided a basis for training drug-detection animals.

Consecutive treatments of methamphetamine promote the development of cardiac pathological symptoms in zebrafish

Chronic methamphetamine use, a widespread drug epidemic, has been associated with cardiac morphological and electrical remodeling, leading to the development of numerous cardiovascular diseases. While methamphetamine has been documented to induce arrhythmia, most results originate from clinical trials from users who experienced different durations of methamphetamine abuse, providing no documentation on the use of methamphetamine in standardized settings. Additionally, the underlying molecular mechanism on how methamphetamine affects the cardiovascular system remains elusive. A relationship was sought between cardiotoxicity and arrhythmia with associated methamphetamine abuse in zebrafish to identify and to understand the adverse cardiac symptoms associated with methamphetamine. Zebrafish were first treated with methamphetamine 3 times a week over a 2-week duration. Immediately after treatment, zebrafish underwent electrocardiogram (ECG) measurement using an in-house developed acquisition system for electrophysiological analysis. Subsequent analyses of cAMP expression and Ca2+ regulation in zebrafish cardiomyocytes were conducted. cAMP is vital to development of myocardial fibrosis and arrhythmia, prominent symptoms in the development of cardiovascular diseases. Ca2+ dysregulation is also a factor in inducing arrhythmias. During the first week of treatment, zebrafish that were administered with methamphetamine displayed a decrease in heart rate, which persisted throughout the second week and remained significantly lower than the heart rate of untreated fish. Results also indicate an increased heart rate variability during the early stage of treatment followed by a decrease in the late stage for methamphetamine-treated fish over the duration of the experiment, suggesting a biphasic response to methamphetamine exposure. Methamphetamine-treated fish also exhibited reduced QTc intervals throughout the experiment. Results from the cAMP and Ca2+ assays demonstrate that cAMP was upregulated and Ca2+ was dysregulated in response to methamphetamine treatment. Collagenic assays indicated significant fibrotic response to methamphetamine treatment. These results provide potential insight into the role of methamphetamine in the development of fibrosis and arrhythmia due to downstream effectors of cAMP.

Prevalence of illicit drug use in young patients with sudden cardiac death

BACKGROUND

Illicit drug use may accelerate coronary disease and cardiac hypertrophy or stimulate arrhythmias. Rates of illicit drug use in young patients with sudden cardiac death (SCD) are uncertain.

OBJECTIVE

The purpose of this study was to identify rates of illicit drug use in young patients with SCD.

METHODS

A prospective statewide registry identified out-of-hospital patients with cardiac arrest aged 18-50 years from April 2019 to April 2021. Clinical characteristics were compared between patients with and without illicit drug use (defined by toxicological results or reported regular use). Illicit drugs included amphetamine-type substances, cocaine, heroin, cannabis, and other drugs.

RESULTS

A total of 554 (40.2%) of 1378 patients had confirmed cardiac cause of out-of-hospital cardiac arrest, with 523 undergoing toxicological assessment. There were 170 patients (32.5%) having either positive toxicology for illicit drugs (n = 138) or negative toxicology but reported regular drug use (n = 32). Patients with SCD and illicit drug use were more commonly male (81.2% vs 72.3%; P = .028), smokers (38.8% vs 19.8%; P ≤ .0001), and excess alcohol drinkers (30.6% vs 20.6%; P = .012) and had a psychiatric diagnosis (38.8% vs 25.7%; P = .002), lower body mass index (29.4 kg/m2 vs 31.7 kg/m2; P = .0063), and lower rates of hypertension (10.6% vs 18.6%; P = .019). Death commonly occurred while sedentary (47.5%) or during sleep (45.8%). Accounting for these baseline differences, there were no differences in rates of coronary disease or cardiomyopathy. Cannabis (n = 106) was the most common illicit drug identified and polysubstance abuse occurred frequently (n = 25).

CONCLUSION

Approximately one-third of young patients with SCD have positive toxicology at the time of death or reported frequent use of illicit drugs, with high rates of polysubstance abuse.

Practice Considerations for the Methamphetamine Use Disorder Patient

Methamphetamine substance use disorders (SUD) are a topic of increasing concern in the United States or America and continue to impact families and communities throughout the United States. Methamphetamine users account for approximately 1.6 million individuals. It is important for health care providers to be aware of the potential lethal impacts of restraining aggressive individuals. It is equally important to understand the impacts of increased circulating catecholamines or subsequent dearth after methamphetamine use and how medications may impact either state. Methamphetamine SUD patients can pose challenges to health care workers, however, safe and effective care is obtainable.

Anesthetic management of a patient with methamphetamine-associated pulmonary arterial hypertension undergoing laparoscopic cholecystectomy

BACKGROUND

Methamphetamine abuse is a serious public health concern and causes various life-threatening disorders including pulmonary arterial hypertension (PAH). Herein, we present the first case report describing the anesthetic management of a patient with methamphetamine-associated PAH (M-A PAH) undergoing laparoscopic cholecystectomy.

CASE PRESENTATION

A 34-year-old female with M-A PAH suffered from deterioration of right ventricular (RV) heart failure due to recurrent cholecystitis and was scheduled for laparoscopic cholecystectomy. Preoperative assessment of PA pressure showed 82/32 (mean, 50) mmHg, and transthoracic echocardiology revealed a slight reduction of RV function. General anesthesia was induced and maintained by thiopental, remifentanil, sevoflurane, and rocuronium. PA pressure gradually increased after peritoneal insufflation; therefore, we administered dobutamine and nitroglycerin to decrease pulmonary vascular resistance (PVR). The patient emerged from anesthesia smoothly.

CONCLUSIONS

Avoiding increased PVR by appropriate anesthesia and medical hemodynamic support is an important consideration for patients with M-A PAH.

Nrf2 attenuates methamphetamine-induced myocardial injury by regulating oxidative stress and apoptosis in mice

OBJECTIVES

Methamphetamine (MA) abuse is a serious social problem worldwide. Cardiovascular complications were the second leading cause of death among MA abusers. We aimed to clarify the effects of MA on myocardial injury, oxidative stress, and apoptosis in myocardial cells and to explore the potential mechanism of nuclear factor-erythroid factor 2-related factor 2 (Nrf2) in MA-induced oxidative stress and apoptosis.

METHODS

An acute cardiac toxicity model of MA was established by intraperitoneal injection of MA (2 mg/kg) for 5 days. Nrf2 activation (by sulforaphane (SFN) 1 h before MA injection) and Nrf2 gene knockout were performed to explore the regulatory effects of Nrf2 on cardiac toxicity.

RESULTS

The protein expressions of Nrf2 (p < .001) and heme oxygenase-1 (HO-1) were increased (p < .01), suggesting that MA activated the Nrf2/HO-1 pathway. In the MA group, cardiac injury score (p < .001) and cardiac troponin I (cTnI) protein expression increased (p < .01). Malondialdehyde (MDA) content increased (p < .001), superoxide dismutase (SOD) activity decreased (p < .05). Protein expressions of Caspase-3 (p < .001) and Bax (p < .001) increased, and Bcl-2 decreased (p < .001) as well. These changes were reversed by activation of Nrf2 but became more pronounced after Nrf2 knockout, suggested that the activation and knockout of Nrf2 attenuated and aggravated MA-induced myocardial injury, oxidative stress and apoptosis in myocardial cells, respectively.

CONCLUSIONS

MA administration induced myocardial injury, oxidative stress, and apoptosis in mice. Nrf2 attenuated MA-induced myocardial injury by regulating oxidative stress and apoptosis, thus playing a protective role.

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.

A Review of Methods Used to Detect Methamphetamine from Indoor Air and Textiles in Confined Spaces

Methamphetamine manufacture, use, and the resulting contamination is a significant issue that affects public health, the environment, and the economy. Third-hand exposure to methamphetamine can result in adverse health risks for individuals and first responders. Such exposures can result from the inhalation of airborne residues or from contact with contaminated objects. This review was conducted to determine the current methods used for methamphetamine extraction from indoor air and porous fabric materials. Dynamic solid phase microextraction (SPME) and sorbent sampling tubes have been applied to extract airborne methamphetamine residues from contaminated properties. SPME and solvent extraction have been applied to sample clothing and textiles for methamphetamine detection. This review demonstrates that there is limited literature on the detection of methamphetamine from indoor air and clothing. Supplementary and consistent methods to detect methamphetamine from air and porous surfaces should be developed and published to allow better assessment of the environmental risk to public health caused by third-hand exposure to methamphetamine.

The effects of methamphetamine on electrocardiographic parameters in male patients

OBJECTIVE

We aimed to compare the electrocardiographic parameters in patients with methamphetamine use to healthy controls.

METHODS

The study is a cross-sectional case-control study. Sixty-eight patients diagnosed with methamphetamine use disorder (MUD) according to DSM-5 criteria and 65 subjects in healthy control group who can match the patient group with demographic data were included in the study. Heart rate, P wave dispersion, QT dispersion, QTc and Tp-e/QTc ratios were calculated in the ECGs of all participants.

RESULTS

The mean age of the patients was 25.60 ± 5.70 and of the control group was 27.43 ± 6.10 (p = 0.076). There was no statistically significant difference between the blood pressure, body mass index, HDL-LDL-total cholesterol and triglyceride values of the participants (p > 0.05). Although QT dispersion was 13.68 ± 9.12 in patients with methamphetamine use disorder, it was calculated as 9.08 ± 7.85 in the control group (p = 0.002). Finally, the Tp-e/QTc ratio of the patients was higher than the healthy controls (p = 0.014).

CONCLUSION

In our study, we found a significant deterioration in QT dispersion and Tp-e/QTc ratio in the MUD group. Therefore, it should be kept in mind that there is a risk of malignant arrhythmia in this patient group and care should be taken in terms of arrhythmic events during follow-up in this patient group.Key pointsPatients with methamphetamine use showed significant deterioration in QTd and Tp-e/QTcMethamphetamine users have prolonged Tp-e/QTc ratio and QTdCaution should be exercised in terms of arrhythmic events in methamphetamine users.

Impaired Brain-Heart Relation in Patients With Methamphetamine Use Disorder During VR Induction of Drug Cue Reactivity

Methamphetamine use disorder (MUD) is an illness associated with severe health consequences. Virtual reality (VR) is used to induce the drug-cue reactivity and significant EEG and ECG abnormalities were found in MUD patients. However, whether a link exists between EEG and ECG abnormalities in patients with MUD during exposure to drug cues remains unknown. This is important from the therapeutic viewpoint because different treatment strategies may be applied when EEG abnormalities and ECG irregularities are complications of MUD. We designed a VR system with drug cues and EEG and ECG were recorded during VR exposure. Sixteen patients with MUD and sixteen healthy subjects were recruited. Statistical tests and Pearson correlation were employed to analyze the EEG and ECG. The results showed that, during VR induction, the patients with MUD but not healthy controls showed significant [Formula: see text] and [Formula: see text] power increases when the stimulus materials were most intense. This finding indicated that the stimuli are indiscriminate to healthy controls but meaningful to patients with MUD. Five heart rate variability (HRV) indexes significantly differed between patients and controls, suggesting abnormalities in the reaction of patient's autonomic nervous system. Importantly, significant relations between EEG and HRV indexes changes were only identified in the controls, but not in MUD patients, signifying a disruption of brain-heart relations in patients. Our findings of stimulus-specific EEG changes and the impaired brain-heart relations in patients with MUD shed light on the understanding of drug-cue reactivity and may be used to design diagnostic and/or therapeutic strategies for MUD.

Ischemic Heart Disease in Young Women: JACC Review Topic of the Week

The Cardiovascular Disease in Women Committee of the American College of Cardiology convened a working group to develop a consensus regarding the continuing rise of mortality rates in young women aged 35 to 54 years. Heart disease mortality rates in young women continue to increase. Young women have increased mortality secondary to ischemic heart disease (IHD) compared with comparably aged men and similar mortality to that observed among older women. The authors reviewed the published evidence, including observational and mechanistic/translational data, and identified knowledge gaps pertaining to young women. This paper provides clinicians with pragmatic, evidence-based management strategies for young women at risk for IHD. Next-step research opportunities are outlined. This report presents highlights of the working group review and a summary of suggested research directions to advance the IHD field in the next decade.

Impact of maternal substance use on offspring's cardiovascular health

Substance use (SU) during pregnancy is on the rise, posing significant risks to the developing fetus. The adverse impact of maternal alcohol and nicotine use during the perinatal period on offspring health has been well established, including their associations with adverse cardiovascular health in offspring. However, limited studies examine the impact of other well-known SU utilized during pregnancy on offspring's cardiovascular health. This review summarizes the proposed mechanism of action of four commonly utilized substances: cocaine, marijuana, methamphetamine, and opioids, and their cardiovascular impact. Furthermore, we will review the current understanding of the adverse impact of substance use during pregnancy on offspring's cardiovascular system based on existing studies. This review will also highlight possible molecular mechanisms underlying the in-utero adverse programming of offspring's cardiovascular system secondary to SU in pregnancy and address the gaps in current understanding of how SU adversely impacts the developing cardiovascular system of offspring in utero.

Methamphetamine induces thoracic aortic aneurysm/dissection through C/EBPβ

AIMS

Thoracic aortic aneurysm/dissection (TAAD) is a life-threatening disease with diverse clinical manifestations. Although the association between methamphetamine (METH) and TAAD is frequently observed, the causal relationship between METH abuse and aortic aneurysm/dissection has not been established. This study was designed to determine if METH causes aortic aneurysm/dissection and delineate the underlying mechanism.

METHODS AND RESULTS

A new TAAD model was developed by exposing METH to SD rats pre-treated with lysyl oxidase inhibitor β-aminopropionitrile (BAPN). Combination of METH and BAPN caused thoracic aortic aneurysm/dissection in 60% of rats. BAPN+METH significantly increased the expression and activities of both matrix metalloproteinase MMP2 and MMP9, consistent with the severe elastin breakage and dissection. Mechanistically, METH increased CCAAT-enhancer binding protein β (C/EBPβ) expression by enhancing mothers against decapentaplegic homolog 3 (Smad3) and extracellular regulated protein kinase (ERK1/2) signaling. METH also promoted C/EBPβ binding to MMP2 and MMP9 promoters. Blocking C/EBPβ significantly attenuated METH+BAPN-induced TAAD and MMP2/MMP9 expression. Moreover, BAPN+METH promoted aortic medial smooth muscle cell (SMC) apoptosis through C/EBPβ-mediated IGFBP5/p53/PUMA signaling pathways. More importantly, the expression of C/EBPβ, MMP2/MMP9, and apoptosis-promoting proteins was increased in the aorta of human patients with thoracic aortic dissection, suggesting that the mechanisms identified in animal study could be relevant to human disease.

CONCLUSIONS

Our study demonstrated that METH exposure has a casual effect on TAAD. C/EBPβ mediates METH-introduced TAAD formation by causing elastin breakage, medial cell loss and degeneration. Therefore, C/EBPβ may be a potential factor for TAAD clinical diagnosis or treatment.

Prescribed opioid use is associated with adverse cardiovascular outcomes in community-dwelling older persons

AIMS

Prescribed opioids are commonly used in the older community-dwelling population for the treatment of chronic pain. Although the harmful effects of opioid abuse and overdose are well understood, little is known about the long-term cardiovascular (CV) effects of prescribed opioids. The aim of this study was to investigate the CV effects associated with prescribed opioid use.

METHODS AND RESULTS

A post hoc analysis of participants in the Aspirin in Reducing Events in the Elderly (ASPREE) trial was conducted. Participants in the ASPREE trial included community-dwelling older adults without a prior history of CV disease (CVD). Prescribed opioid use was defined as opioid use at baseline and/or at the first annual visit (AV1). Cox proportional hazards regression was used to calculate hazard ratios and 95% confidence intervals (95% CI) for associations between opioid use and CVD events following AV1. Of the 17 701 participants included (mean age 75.2 years, 58.2% female), 813 took opioids either at baseline or at AV1. Over a median follow-up period of 3.58 years (IQR 2.50-4.62), CVD events, most notably heart failure hospitalization, occurred in 7% (n = 57) amongst opioid users and 4% (n = 680) amongst non-opioid users. After adjustment for multiple covariates, opiate use was associated with a 1.67-fold (CI 1.26-2.23, P < 0.001) increase in the hazard ratio for CVD events.

CONCLUSIONS

These findings identify opioid use as a non-traditional risk factor for CVD events in community-dwelling older adults.

Effect of High-Intensity Interval Training on Cardiac Apoptosis Markers in Methamphetamine-Dependent Rats

Chronic methamphetamine use increases apoptosis, leading to heart failure and sudden cardiac death. Previous studies have shown the importance of high-intensity interval training (HIIT) in reducing indices of cardiac tissue apoptosis in different patients, but in the field of sports science, the molecular mechanisms of apoptosis in methamphetamine-dependent rats are still unclear. The present article aimed to investigate the changes in cardiac apoptosis markers in methamphetamine-dependent rats in response to HIIT. Left ventricular tissue was used to evaluate caspase-3, melusin, FAK, and IQGAP1 gene expression. Rats were divided into four groups: sham, methamphetamine (METH), METH-control, and METH-HIIT. METH was injected for 21 days and then the METH-HIIT group performed HIIT for 8 weeks at 5 sessions per week. The METH groups showed increased caspase-3 gene expression and decreased melusin, FAK, and IQGAP1 when compared to the sham group. METH-HIIT showed decreased caspase-3 and increased melusin and FAK gene expression compared with the METH and METH-control groups. The IQGAP1 gene was higher in METH-HIIT when compared with METH, while no difference was observed between METH-HIIT and METH-control. Twenty-one days of METH exposure increased apoptosis markers in rat cardiac tissue; however, HIIT might have a protective effect, as shown by the apoptosis markers.

Early onset cardiovascular disease related to methamphetamine use is most striking in individuals under 30: A retrospective chart review

•

Prior MA is associated with an earlier onset of cardiovascular onset which is striking in young adults.

•

Both the races displayed the prior MA use associated earlier age of CVD onset with marked differences in the latency to cardiovascular onset between the Blacks and Whites.

•

Hypertension emerged as the most frequently observed CVD in the MA group.

Introduction

The illicit use of methamphetamine (MA), a dangerous psychostimulant has become a global epidemic. Studies have demonstrated a link between illicit substance use and cardiovascular consequences. The objective of this study was to assess whether MA use is associated with an early onset of cardiovascular diseases (CVD).

Methods

Retrospective analysis was conducted using data collected from 1376 individuals at Louisiana State University Health Sciences Center - Shreveport between 2011 and 2020. Cardiovascular patients with and without a history of MA use were divided into the MA and Control groups. The age of CVD onset was assessed. Descriptive statistics for patient characteristics, Two Samples T-Test for continuous and Pearson's χ^2- tests for categorical variables were calculated. Hazard ratios (HR) and time ratios (TR) were calculated.

Results

The age of CVD onset in patients with prior MA use occurred on average 8 year earlier than the age of CVD onset (mean age ± SD = 44 ± 12.04) in controls (mean age ± SD = 52 ± 10.70) (unpaired t-test, p < 0.0001). The findings were noted in both the races (Time Ratio = 0.93, 95% CI = 0.89 to 0.97, p-value < 0.001), with a striking difference in the latency to CVD onset between Black and White subjects. A 12-fold increase in subjects who showed a premature onset of CVD (<30 years of age) in the MA group was observed. Our data analysis revealed that hypertension was the most frequently observed CVD.

Conclusions

MA use likely accelerates early onset of CVD and contributes to CVD complications in young adults.

Methamphetamine-Associated Cardiomyopathy: Addressing the Clinical Challenges

The growth in methamphetamine usage worldwide continues to present increasing societal and health care challenges. With the escalation of its usage in a variety of social demographics, the entity of methamphetamine-associated cardiomyopathy (MA-CMP) has emerged. This entity is increasingly responsible for an important proportion of heart failure burden in both admissions to hospital and in those individuals requiring chronic heart failure care. MA-CMP poses some unique challenges including its recognition, particularly in younger patients presenting with new-onset heart failure, its severity at presentation and complications as well as management options. The challenging nature of methamphetamine addiction and the necessity to achieve abstinence is a fundamental aspect of management of this condition. As methamphetamine use continues at high levels in Australia, the burden of MA-CMP will inevitably increase and, therefore, all clinicians responsible for heart failure management require an awareness of this disease entity and the specific clinical challenges of its care.

Relationship Between Marijuana Use and Hospitalization for Acute Coronary Syndrome

Background: Recreational marijuana use is rising, especially among young adults. The cardiovascular (CVD) effect of marijuana remains mostly unknown.

Methods: This is a retrospective study of 14,490 patients admitted to our hospital between 2012 and 2014 who had urine toxicology done for various reasons. Patients with a primary diagnosis of acute coronary syndrome (ACS) were queried in both the marijuana-positive group (n = 59) and the marijuana-negative group (n = 195). The risks of having ACS were compared in both groups.

Results: There was no difference in the risk of having ACS between the two groups in the population < 54 years of age (OR: 0.90, 95% CI: 0.67-1.20, p = 0.48). However, there was a significant difference in the risk of having ACS in the 18-36 age group (OR: 2.84, 95% CI: 1.14-7.07, p = 0.01). Multivariate analysis performed to adjust for the potential confounding effects of smoking and cocaine use showed that marijuana use (OR: 0.93, 95% CI: 0.68-1.25, p = 0.65) did not increase the likelihood of ACS for patients ≤ 54 years or for those in the 37-54 age group (OR: 1.11, 95% CI: 0.79-1.53, p = 0.50). However, among the 18-36 age bracket, marijuana use was independently associated with a higher risk of ACS (OR: 5.24, 95% CI: 1.84-16.93, p = 0.002).

Conclusion: In younger patients (age 18-36 years), marijuana use is independently associated with a five-fold higher risk of ACS.

Hemodynamic Effects of Methamphetamine and General Anesthesia

Design

A retrospective analysis of all anesthetic records at our institution over a two-year period was performed. Setting. Operating room cases under balanced anesthesia. Patients. All patients with ASA class I or II, who did not have trauma or were initially admitted to ICU, aged 18–65, without preexisting cardiac, renal, or pulmonary disease. Patients were divided into three groups: those acutely positive for methamphetamine within 48 hours of surgery (n = 137), those positive for methamphetamine between 48 hours and 7 days of surgery (n = 69), and randomly selected controls who were negative for methamphetamine within 7 days of surgery (n = 159). Measurements. Intraoperative hemodynamic instability was defined as either a drop of more than 40% in MAP for greater than 5 minutes or requirement for significant amount of vasopressors. Main Results. Among the patients who were acutely positive for methamphetamine within 24 hours, 31.4% met the criteria for hemodynamic instability within the first hour of general anesthesia, compared to 26.1% of the subacutely positive patients and 6.3% of controls (p < 0.0001). This was despite lower doses of anesthetic medications in the acutely and subacutely positive groups.

Conclusion

Patients who present to the operating room with a positive urine drug screen for amphetamines within 2 days of surgery are at increased risk of hemodynamic instability. Postponing surgery up to 7 days somewhat decreases this risk, but not to the levels of patients who do not use methamphetamines.

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.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.

METHODS

A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered.

STRUCTURE

Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

Understanding Stimulant Use and Use Disorders in a New Era

Extending from the triple wave epidemic of opioid-related overdose deaths, a fourth wave of high mortality involving methamphetamine and cocaine use has been gathering force. This article provides a review of the published literature on stimulants including epidemiology, pharmacology, neurobiology, medical and psychiatric consequences, withdrawal management, and medical and behavioral treatments.

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.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.

METHODS

A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered.

STRUCTURE

Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.

METHODS

A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

Cardiac Complications of Common Drugs of Abuse: Pharmacology, Toxicology and Management

Cardiovascular complications from drugs of abuse are becoming more apparent due to increased usage worldwide. Substance abuse can cause both acute and chronic cardiovascular complications and is increasing in prevalence especially in young adults. These substances contribute to the development of acute coronary syndrome, type II myocardial injury, arrhythmias, cardiomyopathies and have numerous other cardiovascular complications. Although no screening guidelines exist, clinical awareness of these potential complications and their prevention, clinical presentation, diagnosis, and treatment are critically important. Management of cardiovascular disease should be coupled with appropriate social and mental health interventions to provide sustained clinical benefit. The higher the number of substances used recreationally, the greater the risk of premature heart disease. Epidemiological studies showed that 1 in 5 young adults misuse several substances and often start using at younger ages with a greater risk for adverse health outcomes over the long-term. The aim of this review is to highlight the basic epidemiology, cardiac complications, and disease-specific treatment options of commonly abused substances including methamphetamine, cocaine, alcohol, anabolic-androgenic steroids, cannabis, and tobacco.

Drugs of Abuse: Sympathomimetics

Sympathomimetic drugs comprise a broad category of substances including both illicit and prescribed drugs that have deleterious effects when ingested or abused. The clinical syndromes that result from overstimulation of the sympathetic nervous system by reuptake inhibition of biogenic amines, such as norepinephrine and dopamine, carry significant morbidity. Recognition and awareness of the appropriate supportive measures are required to mitigate life-threatening complications of multiple organ systems. The sympathomimetic toxidrome is recognized by a constellation of symptoms including agitation, hyperthermia, tachycardia, and hypertension, and the primary treatment involves supportive care, including the liberal use of benzodiazepines.

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.

Huffing and twist: Fatal Torsade de pointes associated with Tetrafluoroethane Inhalation and amphetamine use

Many volatile chemicals inhaled for a recreational high have a chemical structure similar to chloroform and may lead to Ikr blockade and subsequent torsades de pointes. This is one potential mechanism of action for huffing-associated sudden death.

The Role of HSP90α in Methamphetamine/Hyperthermia-Induced Necroptosis in Rat Striatal Neurons

Methamphetamine (METH) is one of the most widely abused synthetic drugs in the world. The users generally present hyperthermia (HT) and psychiatric symptoms. However, the mechanisms involved in METH/HT-induced neurotoxicity remain elusive. Here, we investigated the role of heat shock protein 90 alpha (HSP90α) in METH/HT (39.5°C)-induced necroptosis in rat striatal neurons and an in vivo rat model. METH treatment increased core body temperature and up-regulated LDH activity and the molecular expression of canonical necroptotic factors in the striatum of rats. METH and HT can induce necroptosis in primary cultures of striatal neurons. The expression of HSP90α increased following METH/HT injuries. The specific inhibitor of HSP90α, geldanamycin (GA), and HSP90α shRNA attenuated the METH/HT-induced upregulation of receptor-interacting protein 3 (RIP3), phosphorylated RIP3, mixed lineage kinase domain-like protein (MLKL), and phosphorylated MLKL. The inhibition of HSP90α protected the primary cultures of striatal neurons from METH/HT-induced necroptosis. In conclusion, HSP90α plays an important role in METH/HT-induced neuronal necroptosis and the HSP90α-RIP3 pathway is a promising therapeutic target for METH/HT-induced neurotoxicity in the striatum.

Echocardiographic Findings in Heart Failure Patients With Methamphetamine Use: A Case-Control Study

Background

Methamphetamine use is associated with cardiovascular disease and significant morbidity and mortality. There is only one previous study performed on echocardiographic parameters in patients with methamphetamine cardiomyopathy.

Methods

We performed a retrospective review of medical records in a county hospital in Southern California with a high population of methamphetamine users. We reviewed medical records and echocardiogram findings in patients seen in our institution from November 2019 to November 2020 who had cardiomyopathy with and without methamphetamine use. We excluded patients who either left the hospital or expired before appropriate assessment. We divided our patient population into a case group (methamphetamine users) and a control group (non-methamphetamine users) to study and compare their echocardiographic parameters.

Results

Case group included a total of 254 patients and control group included 268 patients. Majority of the patient population were males - 178 (70%) and 180 (67%) in the case and control group respectively. Age was found to be statistically significant with the younger population in the case group (p = 0.0000). Our analysis revealed statistically significant difference in methamphetamine users compared to non-users in regards to left ventricle ejection fraction (33.65% ± 18.02 vs. 41.55% ± 15.61, p=0.0000), left ventricle mass index (122.49 grams/m² ± 40.66 vs. 108.62 grams/m² ± 32.82, p=0.0000), left ventricle end diastolic volume index (85.91 mL/m² ± 37.40 vs. 72.44 mL/m² ± 25.44; p=0.0000) and marginally significant right ventricle systolic pressure (42.29mmHg ± 17.53 vs. 39.59mmHg ± 15.61; p=0.0540)

Conclusion

Our results indicated that methamphetamine users had echocardiogram findings with decreased ejection fraction and increased left ventricular mass index, end-diastolic volume index, and right ventricular systolic pressure consistent with worse dilated cardiomyopathy comparison to non-users.

Methamphetamine in Orthopaedics: Considerations of an At-Risk Population

»

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

»

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

»

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

»

Patients who use methamphetamine face elevated rates of complications.

Telomere length is associated with HIV infection, methamphetamine use, inflammation, and comorbid disease risk

BACKGROUND

HIV infection and methamphetamine dependence (METH) are each associated with inflammation and premature aging, but their impact on biological aging is difficult to measure. Here we examined the impact of HIV and METH on leukocyte telomere lengths (LTL), and the correlations between LTL and other aging biomarkers.

METHODS

The study was a cross-sectional analysis of 161 individuals categorized by HIV and methamphetamine (METH) dependence status into four groups: HIV-METH- (n = 50), HIV-METH+ (n = 29), HIV + METH- (n = 40), and HIV + METH+ (n = 42). We analyzed the relationships of leukocyte telomere length (telomere to single copy gene [T/S] ratio) with demographic and clinical data as well as a panel of biomarkers of inflammation and endothelial activation measured in blood and cerebrospinal fluid (CSF).

RESULTS

HIV and METH were independently associated with shorter T/S ratio, even after adjusting for demographics and leukocyte count (R2 = 0·59, p < 0·0001). Higher plasma C-reactive protein (p = 0·0036) and CSF VCAM-1 (p = 0·0080) were also associated with shorter T/S ratio. A shorter T/S ratio was associated with higher risk for cardiovascular disease (p < 0·0001) and stroke (p < 0·0001), worse motor functioning (p = 0·037) and processing speed (p = 0·023), more depressive symptoms (p = 0·013), and higher CSF neurofilament-light (p = 0·003).

CONCLUSIONS

HIV and METH dependence were each associated with shorter telomeres. After adjusting for demographics, HIV, and METH, T/S ratio remained associated with aging-related outcomes including neurocognitive impairment, neurodegeneration, risks of cardiovascular disease and stroke. While not establishing causality, this study supports using the T/S ratio as a biomarker for estimating the impact of HIV and comorbidities on long-term health.

An Intelligent Virtual-Reality System With Multi-Model Sensing for Cue-Elicited Craving in Patients With Methamphetamine Use Disorder

Methamphetamine abuse is getting worse amongst the younger population. While there is methadone or buprenorphine harm-reduction treatment for heroin addicts, there is no drug treatment for addicts with methamphetamine use disorder (MUD). Recently, non-medication treatment, such as the cue-elicited craving method integrated with biofeedback, has been widely used. Further, virtual reality (VR) is proposed to simulate an immersive virtual environment for cue-elicited craving in therapy. In this study, we developed a VR system equipped with flavor simulation for the purpose of inducing cravings for MUD patients in therapy. The VR system was integrated with multi-model sensors, such as an electrocardiogram (ECG), galvanic skin response (GSR) and eye tracking to measure various physiological responses from MUD patients in the virtual environment. The goal of the study was to validate the effectiveness of the proposed VR system in inducing the craving of MUD patients via the physiological data. Clinical trials were performed with 20 MUD patients and 11 healthy subjects. VR stimulation was applied to each subject and the physiological data was measured at the time of pre-VR stimulation and post-VR stimulation. A variety of features were extracted from the raw data of heart rate variability (HRV), GSR and eye tracking. The results of statistical analysis found that quite a few features of HRV, GSR and eye tracking had significant differences between pre-VR stimulation and post-VR stimulation in MUD patients but not in healthy subjects. Also, the data of post-VR stimulation showed a significant difference between MUD patients and healthy subjects. Correlation analysis was made and several features between HRV and GSR were found to be correlated. Further, several machine learning methods were applied and showed that the classification accuracy between MUD and healthy subjects at post-VR stimulation attained to 89.8%. In conclusion, the proposed VR system was validated to effectively induce the drug craving in MUD patients.

Epidemiological Impact of Myocarditis

Myocarditis is an inflammatory disease of the heart muscle with a wide range of potential etiological factors and consequently varying clinical patterns across the world. In this review, we address the epidemiology of myocarditis. Myocarditis was considered a rare disease until intensified research efforts in recent decades revealed its true epidemiological importance. While it remains a challenge to determine the true prevalence of myocarditis, studies are underway to obtain better approximations of the proportions of this disease. Nowadays, the prevalence of myocarditis has been reported from 10.2 to 105.6 per 100,000 worldwide, and its annual occurrence is estimated at about 1.8 million cases. This wide range of reported cases reflects the uncertainty surrounding the true prevalence and a potential underdiagnosis of this disease. Since myocarditis continues to be a significant public health issue, particularly in young adults in whom myocarditis is among the most common causes of sudden cardiac death, improved diagnostic and therapeutic procedures are necessary. This manuscript aims to summarize the current knowledge on the epidemiology of myocarditis, new diagnostic approaches and the current epidemiological impact of the COVID-19 pandemic.

Potential Role of Serum S-100β Protein as a Predictor of Cardiotoxicity and Clinical Poor Outcome in Acute Amphetamine Intoxication

Cardio- and neurotoxicity of amphetamines play an important role in worsening morbidity, making the initial evaluation of the patient's status a potentially lifesaving action. The current study hypothesized that the S-100β serum level could predict the severity of acute amphetamine toxicity and the in-hospital outcome. The current study is a prospective cohort study conducted on 77 patients diagnosed with acute amphetamine exposure and referred to Aseer Poison Control Center, Saudi Arabia. The patients admitted to ICU showed significantly higher serum levels of S-100β in comparison to those not admitted (p < 0.05). Moreover, the S-100β level was significantly elevated among patients with prolonged QTc intervals. Receiver-operating characteristic curve of S-100β serum level as an in-hospital outcome predictor showed that at a cutoff value > 0.430 ug/L, the sensitivity of S-100β serum level as severity predictor was 100%, and the specificity was 74.1%. In conclusion, the current study revealed that the S-100β serum level could be used as an outcome predictor in hospital admission cases due to toxic amphetamine exposure and offers an idea about the cardiac and neuronal involvement. This can help select patients who will benefit most from ICU admission and early management and assess the severity of cases in settings where GC-MS is not available.

Characterization and treatment challenges of pulmonary hypertension in methamphetamine users

The World Health Organization pulmonary hypertension classification scheme provides a framework for evaluation and management of patients with pulmonary vascular disease. Methamphetamine is a recreational stimulant which causes cardiac and pulmonary vascular toxicity. We discuss three cases of methamphetamine users who presented with left ventricular systolic failure but on heart failure therapy developed features more consistent with pulmonary arterial hypertension (PAH) or combined pre-capillary and post-capillary pulmonary hypertension. All three were started on PAH treatment and showed clinical improvement in symptoms. These cases illustrate the difficulty with treating methamphetamine users with pulmonary hypertension who have been left out of randomized controlled trials. Consideration should be given to creating a clinical registry for patients with methamphetamine associated pulmonary hypertension to assist with best treatment strategies.

Methamphetamine and cardiac disease among people with HIV infection

OBJECTIVES

People living with HIV (PWH) are at elevated risk of cardiac disease compared to the general population. Methamphetamine use has been associated with structural heart disease and increased mortality from cardiovascular disease but has not been explored as a cause of cardiac disease among PWH. We sought to evaluate the association of methamphetamine use and cardiac disease among PWH.

METHODS

We performed a case-control study of participant data in the HIV Neurobehavioral Research Program. Cases were defined as PWH with a history of myocardial infarction or a history of heart failure (systolic or diastolic). Covariates, including methamphetamine abuse/dependence, were assessed using multiple logistic regression.

RESULTS

Among 3747 PWH, there was a history of myocardial infarction in 115 subjects (3.1%), and a history of heart failure in 41 (1.1%). Current or prior methamphetamine abuse/dependence was reported in 1036 (27.9%) and was not associated with myocardial infarction (P = 0.27) or heart failure (P = 0.84). In addition to traditional risk factors, variables associated with myocardial infarction included the presence of HIV infection (P = 0.01) and duration of HIV infection (P = 0.05). Variables associated with heart failure among PWH included older age, hypertension and myocardial infarction.

CONCLUSIONS

No association between methamphetamine abuse/dependence and a diagnosis of myocardial infarction or heart failure was found among PWH. Significant covariates for myocardial infarction and heart failure included traditional risk factors, the presence of HIV infection and the duration of HIV infection, emphasizing the need for optimal traditional cardiovascular risk factor management among PWH.

Interoceptive attention in opioid and stimulant use disorder

Blunted anterior insula activation during interoceptive perturbations has been associated with stimulant (cocaine and amphetamine) use disorder (SUD) and is related to risk for and prognosis of SUD. However, little is known whether these interoceptive alterations extend to opioid use disorder (OUD). This exploratory study used the same experimental probe during functional magnetic resonance imaging (fMRI) to test the hypothesis that SUD and OUD exhibit interoceptive discrepancies characterized by subjective ratings and activation within the insula. Recently, abstinent individuals diagnosed with current SUD (n = 40) or current OUD (n = 20) were compared with healthy individuals (CTL; n = 30) on brain and self-report responses during an interoceptive attention task known to elicit insula activation. Participants selectively attended to interoceptive (heartbeat and stomach) and exteroceptive signals during blood-oxygen-level-dependent fMRI recording. Groups and conditions were compared on (a) activation within probabilistic cytoarchitectonic segmentations of the insula and (b) self-reported stimulus intensity. First, SUD showed amplified ratings of heart-related sensations but attenuation of dorsal dysgranular insula activity relative to CTL. Amplified ratings were linked to drug use recency, while attenuation was normalized with greater past-year stimulant use. Second, SUD and OUD showed attenuation of dorsal dysgranular insula activity during attention to stomach sensations relative to CTL. Taken together, these results are consistent with altered neural processing of interoceptive signals in drug addiction, particularly as a function of SUD. Future studies will need to determine whether interoceptive metrics help to explain substance use disorder pathophysiology and are useful for predicting outcomes.

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.

Complications of Methamphetamine Use in Orthopaedic Trauma

OBJECTIVES

To determine whether methamphetamine (MA) users are at an increased risk for complications compared to matched controls in the setting of orthopaedic trauma.

DESIGN

Retrospective cohort study.

SETTING

Academic Level-1 Trauma Center.

PATIENTS

MA users and matched controls.

INTERVENTION

MA use.

MAIN OUTCOME MEASUREMENTS

Infection, Deep Vein Thrombosis (DVT), and nonunion.

RESULTS

Five hundred sixty-seven patients were included in our study (189 MA users, 378 matched controls). On univariate analysis, MA users had a higher incidence of DVT (3.2% vs. 0.5%), but no statistically significant difference in infection or nonunion rates. MA users also had a higher incidence of intensive care unit admission (36.0% vs. 27.8%), leaving the hospital against medical advice (9.0% vs. 2.1%), nonadherence to weightbearing precautions (18.8% vs. 7.3%), and a higher incidence of loss of follow-up (47.1% vs. 30.4%). However, MA users had a lower incidence of surgical treatment for orthopaedic injuries (51.9% vs. 65.9%). When surgical treatment was pursued, more trips to the operating room were required for orthopaedic injuries in the MA group (2.6 vs. 1.5 trips). On multivariate analysis, MA users continued to demonstrate a higher incidence of DVT and a lower incidence of operative management, but more trips to the operating room when surgical management was pursued, a higher admission rate to the intensive care unit, and a greater incidence of loss of follow-up.

CONCLUSIONS

MA use is associated with increased inpatient and outpatient complications.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Increased rupture risk in small intracranial aneurysms associated with methamphetamine use

BACKGROUND

Aneurysmal subarachnoid hemorrhage (SAH) is the most common cause of nontraumatic SAH. Current guidelines generally recommend observation for unruptured intracranial aneurysms smaller than 7 mm, for those are considered at low risk for spontaneous rupture according to available scoring systems.

OBJECTIVE

We observed a tendency for SAH in small intracranial aneurysms in patients who are methamphetamine users. A retrospective, single center study to characterize the size and location of ruptured and unruptured intracranial aneurysms in methamphetamine users was performed.

MATERIALS AND METHODS

Clinical characteristics and patient data were collected via retrospective chart review of patients with intracranial aneurysms and a history of methamphetamine use with a specific focus on aneurysm size and location.

RESULTS

A total of 62 patients were identified with at least one intracranial aneurysm and a history of methamphetamine use, yielding 73 intracranial aneurysms (n = 73). The mean largest diameter of unruptured aneurysms (n = 44) was 5.1 mm (median 4.5, SD 2.5 mm), smaller than for ruptured aneurysms (n = 29) with a mean diameter of 6.3 mm (median 5.5, SD 2.5 mm). Aneurysms measuring less than 7 mm presented with SAH in 36.5%. With regard to location, 28% (n = 42) of anterior circulation aneurysms less than 7 mm presented with rupture, in contrast to 70% (n = 10) of posterior circulation aneurysms which were found to be ruptured.

CONCLUSIONS

Methamphetamine use may be considered a significant risk factor for aneurysmal SAH at a smaller aneurysm size than for other patients. These patients may benefit from a lower threshold for intervention and/or aggressive imaging and clinical follow-up.

Environmental concentration of methamphetamine induces pathological changes in brown trout (Salmo trutta fario)

Methamphetamine, mainly consumed as an illicit drug, is a potent addictive psychostimulant that has been detected in surface water at concentrations ranging from nanograms to micrograms per litre, especially in Middle and East Europe. The aim of this study was to expose brown trout (Salmo trutta fario) to environmental (1 μg L^-1) and higher (50 μg L^-1) concentrations of methamphetamine for 35 days with a four-day depuration phase to assess the possible negative effects on fish health. Degenerative liver and heart alterations, similar to those described in mammals, were observed at both concentrations, although at different intensities. Apoptotic changes in hepatocytes, revealed by activated caspase-3, were found in exposed fish. The parent compound and a metabolite (amphetamine) were detected in fish tissues in both concentration groups, in the order of kidney > liver > brain > muscle > plasma. Bioconcentration factors ranged from 0.13 to 80. A therapeutic plasma concentration was reached for both compounds in the high-concentration treatment. This study indicates that chronic environmental concentrations of methamphetamine can lead to health issues in aquatic organisms.

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.

Methamphetamine-associated pulseless electrical activity in a young child

This is a case report of a 19-month-old female who presented to the emergency department in cardiac arrest after methamphetamine exposure. Prior to presentation, she had seizure-like activity and then became unresponsive. On arrival, she had dilated pupils, intermittent clonus, and pulseless electrical activity. She was found to have full thickness circumferential burns of her bilateral lower extremities. She received 12 doses of epinephrine, cardiopulmonary resuscitation, and volume resuscitation after which she had return of spontaneous circulation and was transferred to the intensive care unit on an epinephrine drip. Initial laboratory studies showed a mixed metabolic and respiratory acidosis and hyperglycemia. An initial urine immunoassay for drugs of abuse was negative, however, 5 h later, a second urine immunoassay was positive for amphetamine. The first specimen was also sent for liquid chromatography-mass spectrometry analysis that later returned positive for methamphetamine and amphetamine. In retrospect, the initial urine screen was found to have evidence of amphetamine below the threshold for positivity (500 ng/mL), and the second urine specimen was highly positive, with an amphetamine level of >1450 ng/mL. In this case, what turned out to be a sub-threshold rather than undetectable level was clinically significant, highlighting the challenges of urine screening in cases of suspected poisoning syndromes with atypical presentations. Our case also suggests the possibility of PEA as a presentation of methamphetamine toxicity in a child.

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.

Substance use disorders: diagnosis and management for hospitalists

Substance use disorder is a significant health concern. Hospitalists manage patient with various forms of substance use disorder on a daily basis. In this review, we have tried to synthesize evidence together to give a brief, yet succinct, review of commonly encounters disorders; alcohol intoxication and withdrawal, opioid intoxication and withdrawal, cocaine intoxication and methamphetamine intoxication. We describe clinical features, diagnosis and management, which would serve as a great resource for hospitalist when managing these complicated patients.