Cannabis, Tobacco, Alcohol Use, and the Risk of Early Stroke: A Population-Based Cohort Study of 45 000 Swedish Men

Heavy Lifetime Cannabis Use and Mortality by Sex

Importance

The association between mortality and cannabis use remains unclear.

Objective

To examine sex-stratified associations of cumulative lifetime cannabis use with all-cause, cardiovascular disease (CVD), and cancer mortality in the UK Biobank population.

Design, Setting, and Participants

This cohort study used data from volunteers in the UK Biobank population. Participant monitoring for mortality in the UK Biobank study commenced from the point of their inclusion between 2006 and 2010 and continued until December 19, 2020. Data regarding the causes of death were sourced from the National Health Service Information Centre. Data were analyzed from inception of study inclusion to December 2020.

Exposure

Cannabis use status was assessed by questionnaire and categorized as heavy, moderate, low, and never.

Main Outcomes and Measures

The main outcomes were all-cause, CVD, and cancer mortality. Sex-stratified associations of cumulative lifetime cannabis use with mortality were estimated using Cox proportional hazards regression with adjustment for demographic and clinical variables.

Results

Among 121 895 participants (54.51% females with mean [SD] age of 55.15 [7.64] years; 45.49% males with mean [SD] age of 56.46 [7.79] years) during an overall median of 11.80 years (IQR, 10.53-13.22 years) of follow-up, 2375 total deaths occurred, including 1411 deaths from CVD and 440 from cancer. In males, after full adjustment, the hazard ratios (HRs) were 1.28 (95% CI, 0.90-1.81) for all-cause mortality, 0.98 (95% CI, 0.43-2.25) for CVD mortality, and 1.09 (95% CI, 0.71-1.67) for cancer mortality among heavy cannabis users compared with never users. In females, after full adjustment, the HRs were 1.49 (95% CI, 0.92-2.40) for all-cause mortality, 2.67 (95% CI, 1.19-4.32) for CVD mortality, and 1.61 (95% CI, 0.91-2.83) for cancer mortality among heavy cannabis users compared with never users. In female current tobacco users, after full adjustment, heavy cannabis use was associated with all-cause mortality (HR, 2.25; 95% CI, 1.12-4.53), CVD mortality (HR, 2.56; 95% CI, 1.43-15.36), and cancer mortality (HR, 3.52; 95% CI, 1.50-8.33) and among never tobacco users was associated with CVD mortality (HR, 2.98; 95% CI, 1.67-6.61). In male current tobacco users, heavy cannabis use was associated with cancer mortality (HR, 2.44; 95% CI, 1.14-5.23).

Conclusions and Relevance

In this study, a positive association between CVD mortality and heavy lifetime cannabis use was observed among females. Longitudinal studies are needed in general populations to investigate the potential effects of cannabis on mortality.

Early-life tobacco smoke exposure and stroke risk: a prospective study of 341,783 and 352,737 UK Biobank participants

INTRODUCTION

Stroke is a life-threatening condition that causes a major medical burden globally. The currently used methods for the prevention or prediction of stroke have certain limitations. Exposure to tobacco in early life, including smoking during adolescence and maternal smoking during pregnancy, can affect adolescent development and lead to several negative outcomes. However, the association between early-life tobacco exposure and stroke is not known.

METHODS

In this prospective cohort study, for the analyses involving exposure to maternal smoking during pregnancy and age of smoking initiation, we included 304,984 and 342,893 participants, respectively., respectively from the UK Biobank. Cox proportional hazard regression model and subgroup analyses were performed to investigate the association between early-life tobacco exposure and stroke. Mediation analyses were performed to identify the mediating role of biological aging in the association between early tobacco exposure and stroke.

RESULTS

Compared with participants whose mothers did not smoke during pregnancy, participants whose mothers smoked during pregnancy showed an 11% increased risk of stroke (HR: 1.11, 95% CI: 1.05-1.18, P < 0.001). Compared with participants who never smoked, participants who smoked during adulthood, adolescence and childhood showed a 22%, 24%, and 38% increased risk of stroke during their adulthood, respectively. Mediation analysis indicated that early-life tobacco exposure can cause stroke by increasing biological aging.

CONCLUSION

This study reveals that exposure to tobacco during early life is associated with an increased risk of experiencing a stroke, and increased biological aging can be the underlying mechanism.

Cannabis, Cannabinoids, and Stroke: Increased Risk or Potential for Protection-A Narrative Review

Worldwide, approximately 15 million people per year suffer from stroke. With about 5 million deaths, stroke is the second most common cause of death and a major cause of long-term disability. It is estimated that about 25% of people older than 85 years will develop stroke. Cannabis sativa and derived cannabinoids have been used for recreational and medical purposes for many centuries. However, due to the legal status in the past, research faced restrictions, and cannabis use was stigmatized for potential negative impacts on health. With the changes in legal status in many countries of the world, cannabis and cannabis-derived substances such as cannabinoids and terpenes have gained more interest in medical research. Several medical effects of cannabis have been scientifically proven, and potential risks identified. In the context of stroke, the role of cannabis is controversial. The negative impact of cannabis use on stroke has been reported through case reports and population-based studies. However, potential beneficial effects of specific cannabinoids are described in animal studies under certain conditions. In this narrative review, the existing body of evidence regarding the negative and positive impacts of cannabis use prior to stroke will be critically appraised.

Association of Cannabis Use With Cardiovascular Outcomes Among US Adults

BACKGROUND

We examined the association between cannabis use and cardiovascular outcomes among the general population, among never-tobacco smokers, and among younger individuals.

METHODS AND RESULTS

This is a population-based, cross-sectional study of 2016 to 2020 data from the Behavioral Risk Factor Surveillance Survey from 27 American states and 2 territories. We assessed the association of cannabis use (number of days of cannabis use in the past 30 days) with self-reported cardiovascular outcomes (coronary heart disease, myocardial infarction, stroke, and a composite measure of all 3) in multivariable regression models, adjusting for tobacco use and other characteristics in adults 18 to 74 years old. We repeated this analysis among nontobacco smokers, and among men <55 years old and women <65 years old who are at risk of premature cardiovascular disease. Among the 434 104 respondents, the prevalence of daily and nondaily cannabis use was 4% and 7.1%, respectively. The adjusted odds ratio (aOR) for the association of daily cannabis use and coronary heart disease, myocardial infarction, stroke, and the composite outcome (coronary heart disease, myocardial infarction, and stroke) was 1.16 (95% CI, 0.98-1.38), 1.25 (95% CI, 1.07-1.46), 1.42 (95% CI, 1.20-1.68), and 1.28 (95% CI, 1.13-1.44), respectively, with proportionally lower log odds for days of use between 0 and 30 days per month. Among never-tobacco smokers, daily cannabis use was also associated with myocardial infarction (aOR, 1.49 [95% CI, 1.03-2.15]), stroke (aOR, 2.16 [95% CI, 1.43-3.25]), and the composite of coronary heart disease, myocardial infarction, and stroke (aOR, 1.77 [95% CI, 1.31-2.40]). Relationships between cannabis use and cardiovascular outcomes were similar for men <55 years old and women <65 years old.

CONCLUSIONS

Cannabis use is associated with adverse cardiovascular outcomes, with heavier use (more days per month) associated with higher odds of adverse outcomes.

Association between cannabis use and ten-year estimated atherosclerotic cardiovascular disease risk in a middle-aged population survey

BACKGROUND

The association between cardiovascular (CV) risk and cannabis use remains inconsistent. The purpose of this study was to examine sex stratified associations of the different lifetime aspects of cannabis use and estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk levels among the general UK Biobank population.

METHODS

Among 104,092 volunteers of the UK Biobank population, cannabis use status was assessed by questionnaire and range as heavy, moderate, low, and never users. Associations between cannabis use and ASCVD risk were estimated using multiple regressions.

RESULTS

Males presented a higher estimated 10-year ASCVD risk compared to females (7.96% vs. 2.24%, p < 0.001) and a higher proportion of heavy lifetime cannabis users (4.00% vs 2.01%, p < 0.001). In all covariate adjusted models, lifetime heavy cannabis use was associated with an increase in estimated 10-year ASCVD risk in both males and females, but with a higher effect among males (in males, B = 0.51 (0.34; 068), in females, B = 0.14 (0.05; 0.23)). When considering high estimated 10-year ASCVD risk (superior to 7.5%), similar results were observed, in males, OR=2.14 [1.82-2.51] and in females: OR=2.07 [1.35-3.17]). The current consumption of cannabis was associated with increased ASCVD risk in both males and females (p < 0.001). When considering the overall population, a significant interaction was observed between sex and cannabis use (p < 0.001).

CONCLUSION

A positive association between estimated 10-year ASCVD risk and heavy lifetime cannabis use was observed but this was higher in males. Longitudinal studies are needed in general populations to highlight the causal effects of cannabis on the atherosclerosis process.

Cannabis and adverse cardiovascular events: A systematic review and meta-analysis of observational studies

Background

Cannabis is the most used illicit drug in the world. Global trends of decriminalization and legalization of cannabis lead to various forms of cannabis use and bring great concerns over adverse events, particularly in the cardiovascular (CV) system. To date, the association between cannabis and adverse CV events is still controversial.

Purpose

We aim to conduct a systematic review and meta-analysis to assess the adverse CV events from cannabis use.

Patients and methods

A systematic search for publications describing the adverse CV events of cannabis use, including acute myocardial infarction (MI) and stroke, was performed via PubMed, Scopus, and Cochrane Library databases. Data on effect estimates in individual studies were extracted and combined via random-effects meta-analysis using the DerSimonian and Laird method, a generic inverse-variance strategy.

Results

Twenty studies with a total of 183,410,651 patients were included. The proportion of males was 23.7%. The median age and follow-up time were 42.4 years old (IQR: 37.4, 50.0) and 6.2 years (IQR: 1.7, 27.7), respectively. The prevalence of cannabis use was 1.9%. Cannabis use was not significantly associated with acute MI (pooled odds ratio (OR): 1.29; 95%CI: 0.80, 2.08), stroke (pooled OR 1.35; 95%CI: 0.74, 2.47), and adverse CV events (pooled OR: 1.47; 95%CI: 0.98, 2.20).

Conclusion

The risk of adverse CV events including acute MI and stroke does not exhibit a significant increase with cannabis exposure. However, caution should be exercised when interpreting the findings due to the heterogeneity of the studies.

Prevalence of Cerebrovascular Accidents Among the US Population With Substance Use Disorders: A Nationwide Study

Introduction Globally, stroke is one of the top ten causes of death. The incidence of stroke in patients aged 44 years and younger was noted to have risen over the past three decades. This rise in stroke diagnosis among young adults could be attributed to multiple reasons, including the rising prevalence of comorbidities like diabetes, hypertension, substance use disorders (SUDs), etc. Aim & objectives This study's primary aim was to evaluate the prevalence of stroke in the US population and the prevalence of SUDs amongst patients with a prior history of stroke. The secondary aim was to evaluate the association between Stroke and SUDs. Methods Our population was obtained from the National Health and Nutrition Examination Survey (NHANES) between the years 2013 to 2018. We identified respondents diagnosed with stroke using the questionnaire and the history of various SUDs amongst this population. The data were analyzed using SAS software (Version 9.4). We performed univariate analysis using the chi-square and Mann-Whitney test, and a p-value of <0.05 was considered statistically significant. Results Two hundred sixty-four thousand seven hundred forty (264,740) respondents were included in this study, and 10435 (3.94%) respondents were noted to have a history of stroke. The population subset with a stroke diagnosis was older (68 years vs. 51 years). Higher prevalence was noted among the female sex (52.14% females vs. 47.86% males), Non-Hispanic white ethnicity, followed by Non-Hispanic black & then other Hispanics (47.56% vs.25.47% vs. 7.82%), and those belonging to a lower annual household income of $0-$25,000 and $25,000-$65,000 ( 46.61% vs. 35.93% ). (p<0.0001). After adjusting for socio-demographics and coexisting comorbidities, e-cigarette [OR: 2.03; 95% CI: 2.03-2.03], cocaine [OR: 1.54; 95%CI:1.54-1.54], heroin [OR: 1.83; 95%CI: 1.83-1.83], marijuana or hashish [OR: 1.01; 95% CI: 1.01-1.01], were observed to have an association with higher odds of stroke than the population without a history of using these illicit drugs.  Conclusion Among respondents with a history of stroke, the use of cocaine was most prevalent, followed by marijuana/hashish, heroin, e-cigarettes, and injecting illegal drugs. The odds of having a stroke were two times higher in the population using an e-cigarette and higher among those using heroin, cocaine, and marijuana/ hashish. The Government should plan policy changes to treat SUDs in the USA, which could help reduce the stroke burden. Recall that bias and geographic variations in response rate by participants of the study were the limitations of our survey-based study.

Cannabis Use and Stroke: Does a Risk Exist?

AIMS

Cannabis use has been reported as a risk factor for stroke. We systematically review the prevalence and outcomes of stroke in people with cannabis use.

METHODS

We searched MEDLINE and 6 other databases from inception to January 2020 for studies on the relationship between cannabis use and stroke. We followed the preferred reporting items for systematic reviews and meta-analyses (PRISMA) recommendations. Two independent reviewers extracted the data. Study quality was assessed by the Newcastle-Ottawa Scale for cohort and case-control studies.

RESULTS

Seventeen studies involving 3,185,560 people with cannabis use were included. Descriptive statistics demonstrated 18,676 (median 1.1%, interquartile range [IQR] 0.3%-1.3%) experienced stroke compared with 0.8% of those without use (Odds Ratio 1.17, 95% CI 1.10-1.25). Among people with cannabis use, median age was 26.2 years (IQR 25.2-34.3 years) and mostly male (median 57.8%). Of stroke subtypes, ischemic stroke was most prevalent (median 1.2%, IQR 0.4%-1.9%), followed by undefined stroke subtype (median 1.2%, IQR 1.1%-1.2%) and hemorrhagic stroke (median 0.3%, IQR 0.1%-0.6%). The majority of people with cannabis use who experienced stroke survived (median: 85.1%, IQR 83%-87.5%) and 64.0% of people experienced a good neurologic outcome, defined as modified Rankin Scale of 0 to 3. Few studies included outcomes of vasospasm or seizure.

CONCLUSIONS

In people with cannabis use, the prevalence of ischemic stroke and hemorrhagic stroke was 1.2% and 0.3%, respectively, higher than the prevalence of people without use (0.8% and 0.2%). There is insufficient information on timing, exposure, duration, and dose-responsive relationship.

Relation of Cannabis Use to Elevated Atherosclerotic Cardiovascular Disease Risk Score

We hypothesized that cannabis use is associated with cardiovascular disease (CVD) risk factors. This could explain the reported link between cannabis and cardiovascular events including stroke and myocardial infarction. This analysis included 7,159 participants (age 37.8 ± 12.4 years, 48.6% men, and 61.5% Caucasian) from the National Health and Nutrition Examination Survey years 2011 to 2018. Cannabis use was defined by self-report. Participants with a history of stroke or myocardial infarction were excluded. Composite CVD risk was assessed using the American College of Cardiology/American Heart Association 10-year atherosclerotic cardiovascular risk (ASCVD) score. Participants were classified based on their ASCVD risk levels as low (<5.0%), borderline (5.0% to 7.4%), intermediate (7.5% to 19.9%), and high (≥20.0%). Multinomial logistic regression was used to examine the association between cannabis use and ASCVD risk category using low-risk ASCVD category as the reference level. About 63.9% (n = 4,573) of participants had ever used cannabis. Ever cannabis use was associated with 60% increased odds of high-risk ASCVD score (odds ratio [OR] 95% confidence interval [CI] 1.60 [1.04 to 2.45], p = 0.03). We also observed a dose-response relation between increased use of cannabis and a higher risk of ASCVD. Those reporting ≥2 uses per month had 79% increased odds of high-risk ASCVD score (OR [95% CI] 1.79 [1.10 to 2.92], p = 0.02) and those reporting ≥1 use per day had 87% increased odds of high-risk ASCVD score (OR [95% CI] 1.87 [1.16 to 3.01], p <0.001]. In conclusion, cannabis use is associated with elevated CVD risk. Individuals using cannabis should be screened for CVD risk, and appropriate risk reduction strategies should be implemented.

Use of Marijuana: Effect on Brain Health: A Scientific Statement From the American Heart Association

Marijuana is perceived as a harmless drug, and its recreational use has gained popularity among young individuals. The concentration of active ingredients in recreational formulations has gradually increased over time, and high-potency illicit cannabinomimetics have become available. Thus, the consumption of cannabis in the general population is rising. Data from preclinical models demonstrate that cannabinoid receptors are expressed in high density in areas involved in cognition and behavior, particularly during periods of active neurodevelopment and maturation. In addition, growing evidence highlights the role of endogenous cannabinoid pathways in the regulation of neurotransmitter release, synaptic plasticity, and neurodevelopment. In animal models, exogenous cannabinoids disrupt these important processes and lead to cognitive and behavioral abnormalities. These data correlate with the higher risk of cognitive impairment reported in some observational studies done in humans. It is unclear whether the effect of cannabis on cognition reverts after abstinence. However, this evidence, along with the increased risk of stroke reported in marijuana users, raises concerns about its potential long-term effects on cognitive function. This scientific statement reviews the safety of cannabis use from the perspective of brain health, describes mechanistically how cannabis may cause cognitive dysfunction, and advocates for a more informed health care worker and consumer about the potential for cannabis to adversely affect the brain.

Risk of cardiovascular diseases in relation to substance use disorders

BACKGROUND

Substance use disorder (SUD) has become increasingly prevalent worldwide, this study investigated the associations of SUD and alcohol, cannabis, opioid, or stimulant use disorder with cardiovascular disease (CVD) and 11 major CVD subtypes.

METHODS

This study was based on a 20% random sample of residents in British Columbia, Canada, who were aged 18 - 80 years at baseline on January 1, 2015. Using linked administrative health data during 2010 - 2014, we identified people with various SUDs and prevalent CVDs at baseline, and examined the cross-sectional associations between SUDs and CVDs. After excluding people with CVDs at baseline, we followed the cohort for 4 years to identify people who developed incident CVDs, and examined the longitudinal associations between SUDs and CVDs.

RESULTS

The cross-sectional analysis at baseline included 778,771 people (mean age 45 years, 50% male), 13,279 (1.7%) had SUD, and 41,573 (5.3%) had prevalent CVD. After adjusting for covariates, people with SUD were 2.7 (95% confidence interval [CI], 2.5 - 2.8) times more likely than people without SUD to have prevalent CVD. The longitudinal analysis included 617,863 people, 17,360 (2.8%) developed incident CVD during the follow-up period. After adjusting for covariates, people with SUD were 1.7 (95% CI, 1.6 - 1.9) times more likely than people without SUD to develop incident CVD. The cross-sectional and longitudinal associations were more pronounced for people with opioid or stimulant use disorder.

CONCLUSIONS

People with SUD are more likely to have prevalent CVD and develop incident CVD compared with people without SUD.

Association between alcohol consumption and the risk of stroke in middle-aged and older adults in China

OBJECTIVE

This study aimed to investigate the association between alcohol consumption and the prevalence of stroke in Chinese adults aged 40 years and over.

METHOD

We conducted a cross-sectional analysis among 113,573 Chinese adults aged ≥ 40 years in the China National Stroke Prevention Project (2014-2015) to examine correlations of alcohol consumption with the prevalence of stroke. Logistic regression models were used to calculate odds ratios (ORs) and 95% confidence intervals (CIs), controlling for various confounders, e.g., gender, age, smoking, physical activity and other health conditions.

RESULTS

Within the study population, a total of 12,753 stroke survivors were identified. The prevalence of light to moderate and of heavy alcohol consumption was 10.1% and 5.7% respectively. The multivariate logistic regression results show that light to moderate alcohol consumption was associated with reduced risk of stroke of all types [0.91 (95%CI: 0.85-0.97)] and of ischemic stroke [0.90 (0.84-0.97)]. No association was found between alcohol consumption and hemorrhagic stroke. Compared with abstainers, the adjusted ORs of all stroke were 0.83 (0.75-0.92) for those who drank 11-20 years, and no association was found between 1 and 10 years or over 20 years of drinking and risk of stroke.

CONCLUSIONS

These results indicate that light to moderate alcohol consumption may be protective against all and ischemic stroke, and heavy drinking was not significantly associated with risk of all stroke in China. No association between alcohol consumption and hemorrhagic stroke was found.

Marijuana Use and the Risk of Early Ischemic Stroke: The Stroke Prevention in Young Adults Study

BACKGROUND AND PURPOSE

Few studies have examined the dose-response and temporal relationships between marijuana use and ischemic stroke while controlling for important confounders, including the amount of tobacco smoking. The purpose of our study was to address these knowledge gaps.

METHODS

A population-based case-control study with 1090 cases and 1152 controls was used to investigate the relationship of marijuana use and early-onset ischemic stroke. Cases were first-ever ischemic stroke between the ages of 15 and 49 identified from 59 hospitals in the Baltimore-Washington region. Controls obtained by random digit dialing from the same geographic region were frequency-matched to cases by age, sex, region of residence and, except for the initial study phase, race. After excluding subjects with cocaine and other vasoactive substance use, the final study sample consisted of 751 cases and 813 controls. All participants underwent standardized interviews to characterize stroke risk factors and marijuana use. Unconditional logistic regression analysis was used to assess the relationships between marijuana use and risk of ischemic stroke, adjusting for age, sex, race, study phase, the amount of current tobacco smoking, current alcohol use, hypertension, and diabetes.

RESULTS

After adjusting for other risk factors, including the amount of current tobacco smoking, marijuana use was not associated with ischemic stroke, regardless of the timing of use in relationship to the stroke, including ever use, use within 30 days, and use within 24 hours. There was a nonsignificant trend towards increased stroke risk among those who smoked marijuana at least once a week (odds ratio, 1.9 [95% CI, 0.8-4.9]).

CONCLUSIONS

These analyses do not demonstrate an association between marijuana use and an increased risk of early-onset ischemic stroke, although statistical power was limited for assessing the association among very heavy users.

Medical cannabis authorization and the risk of cardiovascular events: a longitudinal cohort study

Background

Cannabis is increasingly used for therapeutic purpose. However, its safety profile is not well known. This study assessed the risk of cardiovascular-related emergency department (ED) visit and hospitalization in adult patients authorized to use medical cannabis in Ontario, Canada from 2014 to 2017.

Methods

This is a longitudinal cohort study of patients who received medical cannabis authorization and followed-up in cannabis clinics, matched to population-based controls. The primary outcome was an ED visit or hospitalization for acute coronary syndrome (ACS) or stroke; and secondary outcome was for any cardiovascular event. Conditional Cox proportional hazards regression was used to assess the association between cannabis authorization and risk.

Results

18,653 cannabis patients were matched to 51,243 controls. During a median follow-up of 242 days, the incidence rates for ACS or stroke were 7.19/1000 person-years and 5.67/1000 person-years in the cannabis and controls group, respectively- adjusted hazard ratio (aHR) of 1.44 (95% CI 1.08–1.93). When stratified by sex, the association was only statistically significant among males: aHR 1.77 (1.23–2.56). For the secondary outcome (any CV events), the aHR was 1.47 (1.26–1.72). The aHR among males and females were 1.52 (1.24–1.86) and 1.41 (1.11–1.79), respectively. Tested interaction between cannabis authorization and sex was not significant (p > 0.05).

Conclusions

Medical cannabis authorization was associated with an increased risk of ED visits or hospitalization for CV events including stroke and ACS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02229-6.

Association of Primary Hypertension and Risk of Cerebrovascular Diseases with Overweight and Physical Activity in Korean Women: A Longitudinal Study

Cerebrovascular diseases include stroke, intracranial stenosis, aneurysms, and vascular malformations; primary hypertension is typically associated with cerebrovascular disease. The incidence of these diseases is higher in men than in women, and low physical activity and obesity are known to increase the risk of cerebrovascular disease. This study aimed to longitudinally analyze the adjusted relative risk (ARR) of primary hypertension and cerebrovascular diseases, in relation to body mass index (BMI) and physical activity (PA), in Korean women. The study retrieved the data of 1,464,377 adult Korean women (aged 50–79 years), who participated in the national health screening program from 2002 to 2003. The participants had no history of primary hypertension or cerebrovascular diseases, and were followed up by the International Statistical Classification of Diseases and Related Health Problems (ICD) until 2013. The participants were divided into the following groups: normal weight (18.5–24.9), overweight (25.0–29.9), and obese (≥30.0) kg/m², based on the World Health Organization (WHO) classification. The frequency of PA (days) was determined using a physical activity questionnaire, and defined as low (0–2), medium (3–4), and high (5–7) days. The RR was calculated using Cox regression. Three models were created based on the adjusted variables. The ARR for hypertension was 0.933 (95% CI; 0.920–0.955, p < 0.001) in obese patients with medium PA. Primary hypertension was lower (ARR: 0.943; 95% CI; 0.928–0.961, p < 0.001) in overweight participants with medium PA, than in those with low PA. The incidence of cerebrovascular disease was lower in overweight individuals with medium PA (ARR: 0.945, 95% CI; 0.925–0.976, p < 0.001), than in those with low PA. The risk of cerebrovascular disease was reduced in normal-weight participants with medium PA (ARR: 0.889; 95% CI: 0.854–0.919; p < 0.001), than in those with high PA (ARR 0.913; 95% CI; 0.889–0.953, p < 0.001). In the obese group, there was no significant difference in the risk of cerebrovascular disease, based on the frequency of PA. In conclusion, the relative risk of primary hypertension in women was lower with moderate activity than with low activity, in the normal-weight and overweight groups. The relative risk of cerebrovascular disease was lower in the participants with moderate and high activity than in those with low activity, even at normal weight. In obese individuals, moderate and high activity reduced cerebrovascular disease compared to low activity. Therefore, regardless of obesity, PA may contribute to the prevention of primary hypertension and cerebrovascular disease in adult women.

Cannabis Use and the Risk of Cardiovascular Diseases: A Mendelian Randomization Study

Several observational studies have shown that cannabis use has negative effects on the cardiovascular system, but the causality of this relationship has not been confirmed. The aim of the current study was to estimate the effects of genetically determined cannabis use on risk of cardiovascular diseases. Ten single-nucleotide polymorphisms related to cannabis use were employed as instruments to estimate the association between genetically determined cannabis use and risk of cardiovascular diseases using a two-sample Mendelian randomization (MR) method. Summary statistics data on exposure and outcomes were obtained from different genome-wide association meta-analysis studies. The results of this MR analysis showed no causal effects of cannabis use on the risk of several common cardiovascular diseases, including coronary artery disease, myocardial infarction, stroke and ischemic stroke subtypes, atrial fibrillation (AF), and heart failure. Various sensitivity analyses yielded similar results, and no heterogeneity and directional pleiotropy were observed. After adjusting for tobacco use and body mass index, multivariable MR analysis suggested a causal effect of cannabis use on small vessel stroke (SVS) [odds ratio (OR) 1.17; 95% CI 1.02–1.35; p = 0.03] and AF (OR 1.06; 95% CI 1.01–1.10; p = 0.01), respectively. This two-sample MR study did not demonstrate a causal effect of genetic predisposition to cannabis use on several common cardiovascular outcomes. After adjusting for tobacco use and body mass index, the multivariable MR analysis suggested a detrimental effect of cannabis use on the risk of SVS and AF, respectively.

Marijuana and thromboembolic events in geriatric trauma patients: The cannabinoids clots correlation!

BACKGROUND

Tetrahydrocannabinol (THC) can alter the coagulation cascade resulting in hypercoagulability. The aim of our study is to evaluate the impact of THC use on thromboembolic complications (TEC) in geriatric trauma patients (GTP).

METHODS

This is a 2017 analysis of the TQIP database including all GTP (age ≥65 years). Patients were stratified based on THC use. Propensity score matching (1:2 ratio) was performed.

RESULTS

A total of 2,835 patients were matched (THC+: 945 and THC-: 1,890). Mean age was 70 ± 6 years, 94% sustained blunt injuries, and median ISS was 22[12-27]. Sixty-two percent of patients received thromboprophylaxis, with median time to initiation of 27 h from admission. Overall, the rate of TEC was 2.1% and mortality was 6.0%. THC + patients had significantly higher rates of TEC compared to THC- patients (3.0% vs. 1.7%; p = 0.01). Rates of DVT (2.2% vs 0.6%, p < 0.01) and PE (1.4% vs 0.4%, p < 0.01) were higher in the THC + group.

CONCLUSION

THC exposure increases the risk of TEC in GTP. Incorporation of THC use into risk assessment protocols merits serious consideration in GTP.

Implication of problematic substance use in poststroke depression: an hospital-based study

The prevalence of clinically defined problematic substance use among stroke patients is overlooked and its association with post-stroke depression (PSD) is unknown. Our aims were to: (1) estimate the proportion of stroke patients with a problematic substance use as defined by clinical screening scales; (2) determine the proportion of PSD at three months of follow-up; (3) explore if the baseline severity in substance use and its evolution are independent predictors of PSD. A cohort of first-ever non-severe stroke adult patients was screened at baseline and three months post-stroke using recommended cut-off scores of standardized scales for tobacco, alcohol and cannabis abuse. PSD was defined using the Center of Epidemiological Studies Depression scale score. Out of the 244 eligible patients, 74 (30.3%) presented a problematic substance use, including 21 (8.6%) polydrug abusers. Among these patients, the prevalence of PSD was 50.8%, including 29.5% of severe depression. The severity of tobacco dependence at baseline was found to double the risk (OR 1.59, 95% CI 1.05–2.43) of presenting a PSD, independently of previously reported risk factors. We found no significant evidence for an effect of the evolution in substance use at follow-up. Addictive disorders are part of the critical unmet needs that should be addressed in the management of PSD.

Association between neurological outcome and poststroke comorbid mood and anxiety disorders: A real-life experience

INTRODUCTION

Poststroke depression (PSD) and anxiety (PSA) are prevalent and have a strong impact on functional outcome. Beside stroke severity, little is known on their clinical determinants. This study investigated the association between stroke mechanism, neurological poststroke complications and remaining vascular risk factors and the presence of comorbid PSD and PSA, termed poststroke emotional distress (PSED).

METHODS

This was a retrospective analysis of a prospectively compiled medical records database of consecutive patients evaluated during a follow-up visit 3- to 4-month poststroke. HAD scale was used to define PSED category (PSD+PSA vs. NoPSD+NoPSA). Stroke mechanism and poststroke complications were identified clinically or using appropriate scales. Their association with PSED was tested using a multivariate logistic regression model.

RESULTS

The sample included 2,300 patients (male: 64.8%); 19% had a PSED and 56.39% were free of any depression or anxiety. The most frequent poststroke complications were fatigue/fatigability (58.4%), sleep problems (26.7%), and pain (20.4%). While no association was observed between PSED and stroke mechanism, higher functional disability (OR:1.572), lower cognitive abilities (OR:0.953), sleep problems (OR:2.334), pain (OR:1.478), fatigue/fatigability (OR:2.331), and abnormal movements (OR:2.380) were all independent risk factors. Persisting tobacco consumption (OR:1.360) was the only vascular significant risk factor.

CONCLUSIONS

The frequency of comorbid PSED remains high (1/5 patient) despite improved awareness of these conditions. The association between poststroke complications and the presence of PSED emphasizes the need for standardized neurological and psychological evaluations at follow-up. These results foster the need to improve the management of addictive behaviors to reduce the burden of PSED.

The growing dilemma of legalized cannabis and heart transplantation

This in-depth review discusses cannabis as it relates to heart transplantation and the growing dilemma of legalization around the world creating disparities in transplant candidacy. One will learn about two of the most common cannabinoids: Δ⁹-tetrahydrocannabinol (THC) and cannabidiol (CBD). These cannabinoids are metabolized by cytochrome P-450 and P glycoprotein, which are essential for the metabolism of drugs for transplantation, such as calcineurin inhibitors. Addiction, withdrawal, and cannabis use disorder will be reviewed as well as hyperemesis syndrome. Maintaining adequate immunosuppression will depend on a variety of factors, including drug-drug interactions, pharmacokinetics of cannabinoids and chronicity of cannabis usage. These drug interactions are further confounded by varying concentrations of cannabis products available at medical dispensaries. One will also learn about the outcomes of transplant recipients using cannabis such as graft failure and the risk of infections. Although more research is needed to establish transplant guidelines, the available data is concerning and fairness in organ distribution should not vary by transplant program or institution.

Stroke and cannabis use in patients with no cardiovascular risk factors: a systematic review of case reports

INTRODUCTION

Cannabis and its synthetic analogues are currently the most widely consumed illicit substances worldwide. Multiple alterations have been linked to its use, including cerebrovascular disease (CVD) or stroke, whose association with the substance has been based mainly on the hypothesis of transient vasoconstriction, which explains a large proportion of the cases reported. However, epidemiological studies have not performed an individual analysis of patients without other cardiovascular risk factors, which may limit the estimation of the risk of stroke associated with cannabis use alone.

DEVELOPMENT

A systematic literature review was conducted through Medline, EBSCOhost, EMBASE, Lilacs, and Scielo to gather case reports published before 13 May 2016 presenting patients with a diagnosis of CVD or transient ischaemic attack, a history of cannabinoid use, and no other cardiovascular risk factors. Key words such as stroke, cerebrovascular disease, cannabis, and marijuana, among others, were used. A total of 18 case reports were selected from the 566 references found.

CONCLUSIONS

There is a wide variety of reports of stroke associated with cannabis use in patients with no other risk factors. Noteworthy findings were presentation at young age and a strong temporal association, which place cannabis use as a potential risk factor for this population in line with the epidemiological and pathophysiological studies in this area.

Nonmedical Marijuana Use and Cardiovascular Events: A Systematic Review

INTRODUCTION

Although marijuana use has increased since 2012, the perceived risk of adverse outcomes has decreased. This systematic review summarizes articles that examined the association between nonmedical marijuana use (ie, observed smoking, self-report, or urinalysis) and cardiovascular events in observational or experimental studies of adults aged ≥18.

METHODS

We searched Medline, EMBASE, PsycInfo, CINAHL, Cochrane Library Database, and Global Health from January 1, 1970, through August 31, 2018. Of 3916 citations, 16 articles fit the following criteria: (1) included adults aged ≥18; (2) included marijuana/cannabis use that is self-reported smoked, present in diagnostic coding, or indicated through a positive diagnostic test; (3) compared nonuse of cannabis; (4) examined events related to myocardial infarction, angina, acute coronary syndrome, and/or stroke; (5) published in English; and (6) had observational or experimental designs.

RESULTS

Of the 16 studies, 4 were cohort studies, 8 were case-control studies, 1 was a case-crossover study, 2 were randomized controlled trials, and 1 was a descriptive study. Studies ranged from 10 participants to 118 659 619 hospitalizations. Marijuana use was associated with an increased likelihood of myocardial infarction within 24 hours in 2 studies and stroke in 6 studies. Results of studies suggested an increased risk for angina and acute coronary syndrome, especially among people with a history of a cardiovascular event.

CONCLUSION

This review suggests that people who use marijuana may be at increased risk for cardiovascular events. As states expand new laws permitting marijuana use, it will be important to monitor the effect of marijuana use on cardiovascular disease outcomes, perhaps through the inclusion of data on nonmedical marijuana use in diverse national and local surveillance systems.

Recreational substance use among patients with premature atherosclerotic cardiovascular disease

OBJECTIVE

Despite an upsurge in the incidence of atherosclerotic cardiovascular diseases (ASCVD) among young adults, the attributable risk of recreational substance use among young patients has been incompletely evaluated. We evaluated the association of all recreational substances with premature and extremely premature ASCVD.

METHODS

In a cross-sectional analysis using the 2014-2015 nationwide Veterans Affairs Healthcare database and the Veterans wIth premaTure AtheroscLerosis (VITAL) registry, patients were categorised as having premature, extremely premature or non-premature ASCVD. Premature ASCVD was defined as having first ASCVD event at age <55 years for men and <65 years for women. Extremely premature was defined as having first ASCVD event at age <40 years while non-premature ASCVD was defined as having first ASCVD event at age ≥55 years for men and ≥65 years for women. Patients with premature ASCVD (n=135 703) and those with extremely premature ASCVD (n=7716) were compared against patients with non-premature ASCVD (n=1 112 455). Multivariable logistic regression models were used to study the independent association of all recreational substances with premature and extremely premature ASCVD.

RESULTS

Compared with patients with non-premature ASCVD, patients with premature ASCVD had a higher use of tobacco (62.9% vs 40.6%), alcohol (31.8% vs 14.8%), cocaine (12.9% vs 2.5%), amphetamine (2.9% vs 0.5%) and cannabis (12.5% vs 2.7%) (p<0.01 for all comparisons). In adjusted models, the use of tobacco (OR 1.97, 95% CI 1.94 to 2.00), alcohol (OR 1.50, 95% CI 1.47 to 1.52), cocaine (OR 2.44, 95% CI 2.38 to 2.50), amphetamine (OR 2.74, 95% CI 2.62 to 2.87), cannabis (OR 2.65, 95% CI 2.59 to 2.71) and other drugs (OR 2.53, 95% CI 2.47 to 2.59) was independently associated with premature ASCVD. Patients with polysubstance use had a graded response with the highest risk (~9-fold) of premature ASCVD among patients with use of ≥4 recreational substances. Similar trends were observed among patients with extremely premature ASCVD. Gender interactions with substance use were significant (p-interaction <0.05), with recreational substance use and premature ASCVD showing stronger associations among women than in men with premature ASCVD.

CONCLUSIONS

All subgroups of recreational substances were independently associated with a higher likelihood of premature and extremely premature ASCVD. Recreational substance use confers a greater magnitude of risk for premature ASCVD among women. A graded response relationship exists between increasing number of recreational substances used and higher likelihood of early-onset ASCVD.

Cannabis use disorder and the future risk of cardiovascular disease in parous women: a longitudinal cohort study

BACKGROUND

Cannabis use is increasing in women of reproductive age, but whether cannabis use disorders increase the long-term risk of cardiovascular disease in this population is not known. Cannabis may cause tachycardia, hypertension, cerebral vasoconstriction, and other adverse cardiovascular effects and has been associated with acute myocardial infarction and stroke. Data on the long-term effects of cannabis on the cardiovascular system are more limited. We assessed the relationship between cannabis use disorders early in life and the future risk of cardiovascular disease in women.

METHODS

We analyzed a longitudinal cohort of 1,247,035 pregnant women in Quebec, Canada, between 1989 and 2019. The main exposure was current or past history of cannabis use disorders at cohort entry. The main outcome measure included future hospital admission for any cardiovascular disorder during 18,998,986 person years of follow-up. We used Cox proportional hazards regression models adjusted for patient characteristics to compute hazard ratios (HR) and 95% confidence intervals (CI) for the association of cannabis use disorder with the later risk of cardiovascular hospitalization.

RESULTS

Women with cannabis use disorders had a higher incidence of cardiovascular hospitalization than unexposed women (58.4 vs. 33.6 per 10,000 person years). Cannabis use disorder was associated with 1.48 times the risk of cardiovascular hospitalization (95% CI 1.27-1.72), compared with no cannabis use disorder. The association was greater for cannabis with concomitant use of other substances (HR 1.84, 95% CI 1.53-2.21) than for cannabis alone (HR 1.30, 95% CI 0.99-1.72). Cannabis use disorder was strongly associated with hemorrhagic stroke, even with adjustment for other substance use (HR 2.08, CI 1.07-4.05).

CONCLUSIONS

Cannabis use disorders may increase the long-term risk of cardiovascular disease in women, particularly hemorrhagic stroke. However, some of the excess risk may be due to concomitant use of other substances.

The cardiovascular health of prisoners who use cannabis: An exploratory study among hospitalised prisoners

OBJECTIVE

It is essential that health professionals who practice medicine in prison rely on accurate knowledge about their patients to provide them with adapted care. The use of cannabis can influence the health status of prisoners, but data are lacking regarding the potentially related adverse health consequences. The objective of this descriptive study was to describe the cardiovascular outcomes related to cannabis use in prisoners from several detention centres hospitalised in a French hospital.

METHODS

In France, prisoners who require a longer than 48-hour hospitalisation are admitted in specific secured polyvalent units called inter-regional secured hospital units (ISHU). Hospitalisations in the ISHU of Toulouse University Hospital between 2012 and 2016 for cardiovascular disorders potentially related to the use of cannabis were extracted from the French hospital database and analysed using a previously validated methodology. Included patients were those hospitalised for an inaugural cardiovascular event or deterioration of a preexisting cardiovascular illness who declared having used cannabis while imprisoned.

RESULTS

Overall, 31 cardiovascular outcomes were identified in cannabis-using hospitalised prisoners among 411 hospitalisations for cardiovascular disorders (all men, mean age 43±SD years old). All used cannabis (daily: 56%) and tobacco (more than 15 PY: 83.3%), 5 used cocaine, and none used alcohol. The most frequent were coronaropathy (n=13), followed by obliterating arteriopathy of the lower limb (OALL, n=7), arrhythmic cardiomyopathy (n=4), venous thrombosis (n=3), infectious cardiopathy (n=2), and ischemic stroke (n=2).

CONCLUSION

This description of serious cardiovascular outcomes in prisoners who use cannabis provides insights into the clinical features possibly observed in this vulnerable population The findings indicate that 7.5% of hospitalizations of prisoners for cardiovascular disorders are potentially linked to cannabis used in prison.

The association between regular cannabis use, with and without tobacco co-use, and adverse cardiovascular outcomes: cannabis may have a greater impact in non-tobacco smokers

BACKGROUND

Understanding the potential impact of cannabis use on cardiovascular health is increasingly important as cannabis use rises in the U.S. Objectives: This study evaluated the associations between regular cannabis use, with and without tobacco co-use, and cardiovascular outcomes.

METHODS

Analysis of a limited dataset obtained through IBM Watson Health Explorys, a platform integrating electronic health record data. Matched controls using Mahalanobis distance within propensity score calipers were defined for: 1) cannabis-using patients (n = 8,944; 43% female); and subgroups of cannabis-using patients: 2) with an encounter diagnosis for tobacco use disorder (TUD; n = 4,682); and 3) without a TUD diagnosis (non-TUD; n = 4,262). Patients had ≥1 blood pressure measurement and blood chemistry lab result in the MetroHealth System (Cleveland, Ohio). Cannabis-using patients had an encounter diagnosis of cannabis abuse/dependence and/or ≥2 cannabis-positive urine drug screens. Control patients, with no cannabis-use-documentation, were matched to the cannabis-using patients on demographics, residential zip code median income, body mass index, and, for the total sample, TUD-status. Outcomes were encounter diagnosis (yes/no) of cerebrovascular accident (CVA), heart arrhythmia, myocardial infarction, subarachnoid hemorrhage (SAH), and all-cause mortality.

RESULTS

TUD-patients had the greatest prevalence of cardiovascular disease, regardless of cannabis-use indication. In the total sample and non-TUD subgroup, regular cannabis use was significantly associated with greater risk for CVA, arrhythmia, SAH, and mortality. In the TUD subgroup, regular cannabis use was significantly associated with greater risk for arrhythmia and SAH.

CONCLUSIONS

Cannabis use is associated with significantly greater risk of adverse cardiovascular diagnoses and overall death, particularly in non-tobacco users.

Association between recent cannabinoid use and acute ischemic stroke

Background

Studies that have analyzed the association between cannabis use and acute ischemic stroke (AIS) have provided conflicting results. In this study, we aim to determine the association of recent cannabis use detected through urine drug screen (UDS) among patients admitted with AIS.

Methods

A retrospective observational study was performed using the medical records database. All patients aged 18 years and older admitted from January 1, 2015, to December 31, 2017, who underwent urine toxicology testing on admission were included in the analysis. Multivariate logistic regression analysis was performed to analyze independent association between recent cannabis use and AIS.

Results

A total of 9,350 patients were determined to have undergone UDS during admission, and 18% (1,643) of this had a positive urine cannabis test. Unadjusted risk ratio showed a 50% decrease in risk of AIS among cannabis users (risk ratio = 0.505, 95% confidence interval [CI] 0.425-0.600). The effect was lost after adjusting for age, race, ethnicity, sickle cell disease, dyslipidemia, hypertension, obesity, diabetes mellitus, cigarette smoking, atrial fibrillation, and other cardiac conditions (odds ratio 1.038, 95% CI 0.773-1.394).

Conclusion

This is one of the few studies analyzing the association of recent cannabis use and AIS using admission urine toxicology test independent of polysubstance use. Although our study has limitations, we did not find an independent association between recent cannabis use and the incidence of AIS. Further studies using urine toxicology tests with larger sample size and including dosage of cannabis exposure should be conducted.

Cryptogenic Stroke: Anatomy of the Stroke Work-Up

Despite advances in understanding the cause of ischemic stroke, cryptogenic stroke remains a diagnostic and therapeutic challenge for clinicians. Approximately 15% to 40% of all ischemic strokes have no identifiable cause. CS is a diagnosis of exclusion after completing the standard stroke work-up. Further investigation needs to be tailored individually according to results of the clinical evaluation so appropriate secondary prevention strategies can be applied.

Stroke in young cannabis users (18-49 years): National trends in hospitalizations and outcomes

BACKGROUND

Recent legalization of therapeutic and recreational cannabis use makes it imperative to have an insight into odds and trends in young-onset stroke-related hospitalizations among cannabis users (18-49 years).

METHODS

The National Inpatient Sample dataset (2007-2014) was utilized to assess national trends, odds of young-onset stroke-related hospitalizations, and outcomes among cannabis users vs. nonusers using provided discharge weights, strata, and cluster design. The rates are described per 100,000 hospitalizations among cannabis users and non-users.

RESULTS

A total of 3,307,310 hospitalizations were identified among young adults with current or previous cannabis use. Of these, 34,857 (1.1%) were related to young-onset stroke. A relative increase of 13.92% (553 in 2007 to 630 in 2014; p_trend < 0.001) in young-onset stroke admissions was reported among cannabis users. The odds of any stroke (OR 1.16, 95% CI 1.14-1.19, p < 0.001) and acute ischemic stroke (OR 1.41, 95% CI 1.31-1.51, p < 0.001) hospitalizations were considerably higher among cannabis users as compared to nonusers. In-hospital mortality rates were increasing (3.7% to 4.3%) among cannabis users whereas decreasing (7.7% to 5.9%) in nonusers from 2007 to 2014 (p_trend < 0.001). The mean length of stay and the hospitalization charges showed increasing trends in cannabis-related young-onset stroke admissions. There was an increasing trend in young-onset stroke admissions among male cannabis users (578 to 701; p_trend < 0.001) but not among females (516 to 457; p_trend = 0.14). The maximum rise in the young-onset stroke-related admissions was seen in African Americans (743 to 996; p_trend < 0.001).

CONCLUSIONS

We identified rising trends and higher risk (16% higher of overall young-onset stroke, 41% higher of acute ischemic stroke) of stroke-related hospitalizations and worse outcomes among cannabis users aged 18-49 years from 2007 to 2014.

Smoking trajectories and risk of stroke until age of 50 years - The Northern Finland Birth Cohort 1966

Background

Smoking is a well-known risk factor for stroke. However, the relationship between smoking trajectories during the life course and stroke is not known.

Aims

We aimed to study the association of smoking trajectories and smoked pack-years with risk of ischemic and haemorrhagic strokes in a population-based birth cohort followed up to 50 years of age.

Methods

Within the Northern Finland Birth Cohort 1966, 11,999 persons were followed from antenatal period to age 50 years. The smoking behaviour was assessed with postal questionnaires at ages 14, 31 and 46 years. Stroke diagnoses were collected from nationwide registers using unique study number linkage. The associations between smoking behaviour and stroke risk were estimated using Cox regression models.

Results

Six different patterns in smoking habits throughout the life course were found in trajectory modelling. During 542,140 person-years of follow-up, 352 (2.9%) persons had a stroke. Continuous smoking during the life course was associated with increased stroke risk (HR = 1.69; 95% CI 1.10–2.60) after adjusting for sex, educational level, family history of strokes, leisure-time physical activity, body mass index, alcohol consumption, hypertension, hypercholesterolemia, and diabetes. Per every smoked pack-year the stroke risk increased 1.04-fold (95% CI 1.03–1.06). Other smoking trajectories were not significantly associated with stroke risk, nor were starting or ending age of smoking.

Conclusion

Accumulation of smoking history is associated with increased risk of stroke until age of 50 years. The increased stroke risk does not depend on the age at which smoking started. Given that the majority starts smoking at young age, primary prevention of strokes should focus on adolescent smoking.

Marijuana Use Among Young Adults (18-44 Years of Age) and Risk of Stroke: A Behavioral Risk Factor Surveillance System Survey Analysis

Background and Purpose- Amidst legalization of therapeutic and recreational use of marijuana/cannabis in the United States, cerebrovascular effects of marijuana use remain largely unknown, especially among young adults. We aimed to examine the association between marijuana use (18-44 years) among young adults and stroke events. Methods- The study analyzed pooled data from the Behavioral Risk Factor Surveillance System (2016-2017)-a nationally representative cross-sectional survey collected by the Centers for Disease Control and Prevention. Weighted logistic regression models were used to examine an association of recent marijuana use (within the last 30 days) and stroke in young adults (18-44 years) adjusting for patient demographics, risk behavior, and relevant comorbidities. Results- Overall, 13.6% of participants (n=43 860; weighted 35.5 million; 49.9% men) reported using marijuana recently (in the last month), with 63.3% of them being men. Compared with nonusers, marijuana users were often younger (18-34 years; 73.8% versus 61%), non-Hispanic white or black, and with some college education. Marijuana users were often physically active (81.8% versus 77.5%), heavy drinkers (16.8% versus 4.9%), current combustible cigarette users (37.9% versus 15%) and had lower prevalence of hypertension, diabetes mellitus, and hyperlipidemia as compared with nonusers (P<0.01). Young adults with recent marijuana use showed 1.82× higher odds (adjusted odds ratio, 1.82 [95% CI, 1.08-3.10]) of stroke compared with nonusers, which further increased to 2.45× higher (adjusted odds ratio, 2.45 [95% CI, 1.31-4.60]) among frequent marijuana users (>10 days/month). Compared with nonusers, stroke odds were even higher among frequent marijuana users with concomitant combustible cigarette use (adjusted odds ratio, 3.12 [95% CI, 1.40-6.97]) and e-cigarette use (adjusted odds ratio, 2.63 [95% CI, 1.07-6.46]), respectively. Conclusions- There may be a significantly higher odds of stroke in young marijuana users (18-44 years) as compared with nonusers with even greater odds among frequent users (>10 days/month).

Oral Contraceptive Use and Increased Risk of Stroke: A Dose-Response Meta-Analysis of Observational Studies

Background: Oral contraceptive (OCP) use might increase the risk of stroke in women. We examined a possible dose–response relation between OCP use and the risk of stroke in young and middle-aged women.

Methods: A retrieval of PubMed and EMBASE databases was performed. We selected observational studies that reported odds ratios (ORs) with 95% confidence intervals (CIs) for the risk of stroke in OCP users. A two-stage dose–response analysis was conducted using the random-effects model and the restricted spline model.

Results: A total of 6 cohort studies and 12 case–control studies were included, which involved 2,143,174 participants and 11,661 cases of stroke including ischemic stroke (IS), hemorrhagic stroke (HS), and stroke of unknown origin. The pooled ORs of total stroke were 1.19 (95% CI, 1.16–1.23) for every 10-μg increment in estrogen dosage, 1.20 (95% CI, 1.05–1.37) for every 5-years increment in duration of OCP use, and 0.82 (95% CI, 0.68–0.98) for every 5-years increment in duration of OCP cessation. The ORs of IS were 1.20 (95% CI, 1.17–1.22) in estrogen dosage, 1.24 (95% CI, 1.04–1.49) in duration of OCP use, and 0.78 (95% CI, 0.67–0.92) in duration of OCP cessation. The ORs of HS were 1.10 (95% CI, 1.04–1.16) in estrogen dosage, 1.13 (95% CI, 0.93–1.36) in duration of OCPs, and 0.71 (95% CI, 0.55–0.92) in duration of OCP cessation. The pooled ORs of total stroke from prospective studies (1.12; 95% CI, 1.01–1.24) were lower than those from retrospective studies (1.30; 95% CI, 1.01–1.67).

Conclusions: The higher estrogen dosage significantly increased the risks of total stroke, IS, and HS, respectively. The longer duration of OCP use significantly increased the risks of total stroke and IS, but its effects on HS risk were marginal. The longer duration of OCP cessation significantly decreased the risks of total stroke, IS, and HS, respectively. These findings affirm the contribution of estrogen dose and duration of OCP use to the increased risk of stroke, which may be critical for the instruction of OCP use and the prevention and management of cerebrovascular diseases.

A Mechanistic and Pathophysiological Approach for Stroke Associated with Drugs of Abuse

Drugs of abuse are associated with stroke, especially in young individuals. The major classes of drugs linked to stroke are cocaine, amphetamines, heroin, morphine, cannabis, and new synthetic cannabinoids, along with androgenic anabolic steroids (AASs). Both ischemic and hemorrhagic stroke have been reported due to drug abuse. Several common mechanisms have been identified, such as arrhythmias and cardioembolism, hypoxia, vascular toxicity, vascular spasm and effects on the thrombotic mechanism, as causes for ischemic stroke. For hemorrhagic stroke, acute hypertension, aneurysm formation/rupture and angiitis-like changes have been implicated. In AAS abuse, the effect of blood pressure is rather substance specific, whereas increased erythropoiesis usually leads to thromboembolism. Transient vasospasm, caused by synthetic cannabinoids, could lead to ischemic stroke. Opiates often cause infective endocarditis, resulting in ischemic stroke and hypereosinophilia accompanied by pyogenic arthritis, provoking hemorrhagic stroke. Genetic variants are linked to increased risk for stroke in cocaine abuse. The fact that case reports on cannabis-induced stroke usually refer to the young population is very alarming.

Rising Trends in Hospitalizations for Cardiovascular Events among Young Cannabis Users (18-39 Years) without Other Substance Abuse

Background and objectives: Modern-day epidemiologic data on the risk and shifting landscape of occurrence of cardiovascular events in cannabis users remain inadequate and rather conflicting, especially amongst the young adult population. Furthermore, the problem of polysubstance use among youth is challenging for healthcare professionals and policy-makers. Previous studies report higher risk of concomitant use of tobacco, alcohol, cocaine, and amphetamine in young cannabis users. However, most of these studies did not eliminate the confounding effects of concomitant other substance abuse while assessing the incidence and outcome of cardiovascular events in cannabis users. Materials and methods: Using weighted discharge records from the National Inpatient Sample (NIS) from 2007–2014, we assessed the national trends in hospitalizations for major cardiovascular events including acute myocardial infarction (AMI), arrhythmia, stroke, and venous thromboembolic events (VTE) among young cannabis users (18–39 years), excluding cases with concomitant substance abuse with alcohol, tobacco, cocaine, and amphetamine. Results: Of 52.3 million hospitalizations without other substance abuse, 0.7 million (1.3%) young adults were current/former cannabis users. Among young adults without concomitant substance abuse, the frequency of admissions for AMI (0.23% vs. 0.14%), arrhythmia (4.02% vs. 2.84%), and stroke (0.33% vs. 0.26%) was higher in cannabis users as compared to non-users (p < 0.001). However, the frequency of admissions for VTE (0.53% vs. 0.84%) was lower among cannabis users as compared non-users. Between 2007 and 2014, we observed 50%, 79%, 300%, and 75% relative increases in hospitalizations for AMI, arrhythmias, stroke, and VTE, respectively, among young cannabis users as compared to non-users, showing relatively inferior or no ascent in the rates (p_trend < 0.001). Conclusions: The rising trends in hospitalizations for acute cardiovascular events among young cannabis users without concomitant other substance abuse call for future prospective well-designed studies to assess cannabis-related short-and long-term cardiovascular implications while simultaneously developing focused interventions towards raising awareness among the young population regarding the potential deleterious effects of cannabis use.

A commentary on the medicinal use of marijuana

Background

Lately, the number of people using marijuana in the USA has dramatically increased. In 2018, many states have legalized marijuana use for both medical and recreational purposes, thus exploring the evidence behind medical marijuana use became essential. Muslim majority countries enforce rigorous rules as marijuana has been a long-debated issue due to the stigma associated with its use as a treatment. Marijuana has a high beneficial effect in managing chronic pain in adults and relieving spasticity symptoms in multiple sclerosis, obstructive sleep apnea syndrome, and fibromyalgia. As well as, used as pain management, and as anti-emetic in treatment of chemotherapy-induced vomiting and nausea. Marijuana is requested from more than one-third of posttraumatic stress disorder patients due to its significant clinical improvement in nightmares and subsidence disorder symptoms.

Marijuana adversely affects the body’s resistance to many infections, compromising their immune response. Its recreational use has led to an increasing trend in the occurrence of major acute cardiovascular events as stroke, epilepsy, acute myocardial infarction, congestive heart failure, and arrhythmia.

Conclusion

Many countries started to allow medicinal use of marijuana due to its beneficial effect in managing chronic pain, spasticity symptoms in multiple sclerosis, obstructive sleep apnea syndrome, fibromyalgia, and posttraumatic stress disorder. But literature lacks benefit-harm analysis for marijuana usage in medicine. Therefore, evidence-based report of short- and long-term health effects of marijuana use—both harmful and beneficial effects—is crucial for further marijuana prescription in healthcare settings.

Stroke in young adults: Five new things

PURPOSE OF REVIEW

The incidence of stroke in young adults is increasing, mainly driven by an increasing incidence of ischemic stroke in this population. We provide new information that has been recently presented regarding the risk factor prevalence, some specific etiologic causes, and management strategies in ischemic stroke in this population.

RECENT FINDINGS

Recent studies indicate a rapid increase in traditional risk factors in young adults. New information regarding the management of patent foramen ovale in cryptogenic stroke and cervical artery dissection is available.

SUMMARY

Stroke in young adults is a rapidly growing problem with deep public health implications. There are many areas in this field, which require further research.

Uncommon Association of Two Anatomical Variants of Cerebral Circulation: A Fetal-Type Posterior Cerebral Artery and Inferred Artery of Percheron, Complicated with Paramedian Thalamomesencephalic Stroke-Case Presentation and Literature Review

Background

The unilateral fetal variant of the posterior cerebral artery (FPCA) is characterized by the congenital absence of the P1 arterial segment. The artery of Percheron (AOP) is an uncommon vascular variant, in which a single dominant thalamoperforating arterial trunk arises from one P1 segment, bifurcates, and provides bilateral supply to the paramedian thalami and rostral midbrain.

Case Presentation

This is a retrospective case study of a 37-year-old man with multiple lifestyle risk factors (chronic marijuana and tobacco abuse), who suffered a thalamomesencephalic stroke, rapidly worsening to comatose state. After restoration of consciousness, he clinically manifested with left paramedian midbrain syndrome. Imaging demonstrated an asymmetric paramedian thalamic infarction with mesencephalon extension, patency of the basilar, vertebral arteries, and left PCA and right-sided FPCA, respectively. Left-sided thalamoperforating arterioles were not differentiated; AOP was inferred. Neither evident clinical source of embolus nor prothrombotic states were found. Mobile cardiac telemetry and transesophageal echocardiography were not available. The diagnosis was established too late for thrombolytic treatment. Anticoagulation was indicated during the acute and subacute stages, followed by low dose of antiplatelet.

Discussion

This uncommon cerebrovascular configuration (FPCA+AOP) might be the fourth case described in the literature. Sustained rehabilitation and abstinence from tobacco and cannabis led to favorable outcomes.

Lifetime marijuana use and subclinical atherosclerosis: the Coronary Artery Risk Development in Young Adults (CARDIA) study

BACKGROUND AND AIMS

Unlike tobacco, the effect of marijuana smoke on subclinical atherosclerosis, a surrogate measure for cardiovascular disease, is not known. This study aimed to determine the association between lifetime exposure to marijuana and measures of subclinical atherosclerosis in mid-life.

DESIGN, SETTING AND PARTICIPANTS

We used data from the US-based Coronary Artery Risk Development in Young Adults (CARDIA) study, a cohort of black and white men and women aged 18-30 years at baseline in 1985-86, with up to seven follow-up examinations over 25 years. A total of 3498 participants in the CARDIA study were included in this study.

MEASUREMENTS

Cumulative years of exposure to marijuana (expressed in 'marijuana-years', with 1 marijuana-year equivalent to 365 days of use) using repeated assessments every 2-5 years for 25 years. Abdominal artery calcium (AAC) and coronary artery calcium (CAC) scores were measured by computed tomography at year 25 examination.

RESULTS

Among 3117 participants with AAC and CAC measurements, 2627 (84%) reported past marijuana use and 1536 (49%) past daily tobacco smoking. Compared with tobacco smokers, 46% of whom reported 10 or more pack-years of use, only 12% of marijuana users reported 5 or more marijuana-years of use and only 6% reported having used marijuana daily. We found a significant interaction between never and ever tobacco users on the association between cumulative marijuana use and AAC (P = 0.05). Among those who never smoked tobacco, cumulative marijuana-years were not associated with AAC or CAC in models adjusted for demographics, cardiovascular risk factors, licit and illicit drug exposure and depression symptoms. However, among ever tobacco smokers, marijuana exposure was associated with AAC and CAC. At 5 marijuana-years of exposure, using AAC = 0 and CAC = 0 as a reference group, the odds ratio (OR) was 1.97 [95% confidence interval (CI) = 1.21-3.21, P = 0.007] for AAC > 0/CAC = 0 and 1.83 (95% CI = 1.02-3.31, P = 0.04) for CAC > 0), regardless of AAC. Tobacco smoking was associated strongly with both AAC and CAC.

CONCLUSION

Marijuana use appears to be associated with subclinical atherosclerosis, but only among ever tobacco users.

Smoking and Risk of Ischemic Stroke in Young Men

BACKGROUND AND PURPOSE

There is a strong dose-response relationship between smoking and risk of ischemic stroke in young women, but there are few data examining this association in young men. We examined the dose-response relationship between the quantity of cigarettes smoked and the odds of developing an ischemic stroke in men under age 50 years.

METHODS

The Stroke Prevention in Young Men Study is a population-based case-control study of risk factors for ischemic stroke in men ages 15 to 49 years. The χ² test was used to test categorical comparisons. Logistic regression models were used to calculate the odds ratio for ischemic stroke occurrence comparing current and former smokers to never smokers. In the first model, we adjusted solely for age. In the second model, we adjusted for potential confounding factors, including age, race, education, hypertension, myocardial infarction, angina, diabetes mellitus, and body mass index.

RESULTS

The study population consisted of 615 cases and 530 controls. The odds ratio for the current smoking group compared with never smokers was 1.88. Furthermore, when the current smoking group was stratified by number of cigarettes smoked, there was a dose-response relationship for the odds ratio, ranging from 1.46 for those smoking <11 cigarettes per day to 5.66 for those smoking 40+ cigarettes per day.

CONCLUSIONS

We found a strong dose-response relationship between the number of cigarettes smoked daily and ischemic stroke among young men. Although complete smoking cessation is the goal, even smoking fewer cigarettes may reduce the risk of ischemic stroke in young men.

Associations Between Marijuana Use and Cardiovascular Risk Factors and Outcomes: A Systematic Review

BACKGROUND

Marijuana use is increasing in the United States, and its effect on cardiovascular health is unknown.

PURPOSE

To review harms and benefits of marijuana use in relation to cardiovascular risk factors and clinical outcomes.

DATA SOURCES

PubMed, MEDLINE, EMBASE, PsycINFO, and the Cochrane Library between 1 January 1975 and 30 September 2017.

STUDY SELECTION

Observational studies that were published in English, enrolled adults using any form of marijuana, and reported on vascular risk factors (hyperglycemia, diabetes, dyslipidemia, and obesity) or on outcomes (stroke, myocardial infarction, cardiovascular mortality, and all-cause mortality in cardiovascular cohorts).

DATA EXTRACTION

Study characteristics and quality were assessed by 4 reviewers independently; strength of evidence for each outcome was graded by consensus.

DATA SYNTHESIS

13 and 11 studies examined associations between marijuana use and cardiovascular risk factors and clinical outcomes, respectively. Although 6 studies suggested a metabolic benefit from marijuana use, they were based on cross-sectional designs and were not supported by prospective studies. Evidence examining the effect of marijuana on diabetes, dyslipidemia, acute myocardial infarction, stroke, or cardiovascular and all-cause mortality was insufficient. Although the current literature includes several long-term prospective studies, they are limited by recall bias, inadequate exposure assessment, minimal marijuana exposure, and a predominance of low-risk cohorts.

LIMITATION

Poor- or moderate-quality data, inadequate assessment of marijuana exposure and minimal exposure in the populations studied, and variation in study design.

CONCLUSION

Evidence examining the effect of marijuana on cardiovascular risk factors and outcomes, including stroke and myocardial infarction, is insufficient.

PRIMARY FUNDING SOURCE

National Heart, Lung, and Blood Institute. (PROSPERO: CRD42016051297).

Examining the relationship between medical cannabis laws and cardiovascular deaths in the US

BACKGROUND

Several countries and many U.S. states have allowed, for cannabis to be used as therapy to treat chronic conditions or pain., This has increased the use of cannabis, particularly among older people.Because cannabis has been linked to adverse cardiac events in the medical literature, there may be unintended consequences on increased use among older people.

METHODS

We analyze cardiac-related mortality data from the U.S. National Vital Statistics System for 1990-2014. We use difference-in-difference fixed-effects models to assess whether there are increased rates of cardiac-related mortality following passage of medical cannabis programs. We also analyze whether states with more liberal rules on dispensing cannabis show higher mortality rates.

RESULTS

For men, there is a statistically significant 2.3% increase in the rate of cardiac death following passage. For women, there is a 1.3% increase that is also statistically significant. he effects increase or both men and women with age. The effects are also stronger in states with more a lax approach to cannabis dispensing.

CONCLUSION

Policymakers should be aware of a potential unintended consequence of allowing broader use of cannabis, specifically for those more at risk of cardiovascular events.

Efficacy of Tai Chi and qigong for the prevention of stroke and stroke risk factors: A systematic review with meta-analysis

BACKGROUND

This review aims to summarize the evidence of Tai Chi and qigong interventions for the primary prevention of stroke, including the effects on populations with major stroke risk factors.

METHODS

A systematic literature search was conducted on January 16, 2017 using the PubMed, Scopus, Cochrane Library, and CINAHL databases. Randomized controlled trials examining the efficacy of Tai Chi or qigong for stroke prevention and stroke risk factors were included. Risk of bias was assessed using the Cochrane Risk of Bias tool.

RESULTS

Twenty-one trials with n = 1604 patients with hypertension, hyperlipidaemia, diabetes, overweight or obesity, or metabolic syndrome were included. No trials were found that examined the effects of Tai Chi/qigong on stroke incidence. Meta-analyses revealed significant, but not robust, benefits of Tai Chi/qigong over no interventions for hypertension (systolic blood pressure: -15.55 mm Hg (95% CI: -21.16; -9.95); diastolic blood pressure: -10.66 mm Hg (95% CI: -14.90, -6.43); the homeostatic model assessment (HOMA) index (-2.86%; 95% CI: -5.35, -0.38) and fasting blood glucose (-9.6 mg/dL; 95% CI: -17.28, -1.91), and for the body mass index compared with exercise controls (-1.65 kg/m; 95% CI: -3.11, -0.20). Risk of bias was unclear or high for the majority of trials and domains, and heterogeneity between trials was high. Only 6 trials adequately reported safety. No recommendation for the use of Tai Chi/qigong for the prevention of stroke can be given.

CONCLUSION

Although Tai Chi and qigong show some potential more robust studies are required to provide conclusive evidence on the efficacy and safety of Tai Chi and qigong for reducing major stroke risk factors.