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

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.

Perceptions, Attitudes, and Knowledge of Cannabis and its Use: A Qualitative Study among Herbal Heart Study Young Adult Cannabis Consumers in South Florida

Growing cannabis use among young adults in the United States surpasses research and public understanding, raising health concerns despite potential benefits. Limited research focuses on their knowledge, attitudes, risks, and motivations, especially in states with limited legalization. This study explores cannabis knowledge and attitudes among healthy young adult cannabis consumers to understand their risk and benefit perceptions. Data include a subsample of participants in the Herbal Heart Study, a cohort to examine subclinical cardiovascular risk among healthy young adult (18-35 years old) cannabis consumers and non-consumers. A qualitative thematic analysis of the interviews was performed using a deductive approach driven by the theory of the Health Belief Model to generate categories and codes. Dedoose was used to organize transcripts and coding. A total of 22 young adult cannabis consumers (M age = 25.3, SD = 4.4) were interviewed between May 5, 2021- September 23, 2022. Participants were predominantly female (n = 13) and Hispanic (n = 9) or non-Hispanic Black (n = 7). Five themes were identified: perceived health benefits and risks associated with cannabis use, motivation for cannabis use, knowledge of cannabis, and perceived barriers to cannabis use. Participants discussed knowledge, positive/negative attitudes toward cannabis, and perceived risks/benefits based on personal experience and gathered information. Some showed knowledge deficits, and most wanted more health-related cannabis research. Given the current climate of rising cannabis legalization, availability of novel cannabis products, and societal acceptance, further research and evidence-based cannabis literacy for young adults are essential to keep pace with liberalization trends.

Cannabis use and atherosclerotic cardiovascular disease: a Mendelian randomization study

BACKGROUND

Association between cannabis use and development of atherosclerotic cardiovascular disease (ASCVD) is inconsistent and challenging to interpret, given existing study limitations.

METHODS

Sixty five independent single-nucleotide polymorphisms (SNPs), obtained from a genome-wide association study on lifetime cannabis use, were employed as genetic instruments to estimate the effects of genetically indexed cannabis use on risk of coronary artery disease (CAD) and acute ischemic stroke (IS) using a two-sample Mendelian randomization (MR) approach. Summary statistics on CAD (CARDIoGRAMplusC4D; 60,801 cases and 123,504 controls) and IS (MEGASTROKE; 34,217 cases and 406,111 controls) were obtained separately. A comprehensive review of the observational literature on cannabis use and CAD or IS was also performed and contrasted with MR results.

RESULTS

There was no causal effect of cannabis use on the risk of CAD (odds ratio (OR) per ever-users vs. never-users 0.93; 95% confidence interval (CI), 0.83 to 1.03) or IS (OR 1.05; 95%CI, 0.93 to 1.19). Sensitivity analyses yielded similar results, and no heterogeneity and directional pleiotropy was observed. Our meta-analysis of observational studies showed no significant association between ever use of cannabis with risk of CAD (k = 6 studies; ORpooled = 1.23, 95%CI 0.78 to 1.69), nor with IS (k = 6 studies; ORpooled = 1.22, 95%CI 0.95 to 1.50).

CONCLUSION

Using a genetic approach approximating a clinical trial does not provide evidence consistent with a causal effect of genetic predisposition to cannabis use on CAD or IS development. Further studies are needed to replicate our findinds, an to investigate more precisely the risk of ASCVD in relation to the quantity, type, route of administration, or the age at exposure to cannabis.

Role of Cannabinoid Signaling in Cardiovascular Function and Ischemic Injury

Cardiovascular disease represents a leading cause of death, morbidity, and societal economic burden. The prevalence of cannabis use has significantly increased due to legalization and an increased societal acceptance of cannabis. Therefore, it is critically important that we gain a greater understanding of the effects and risks of cannabinoid use on cardiovascular diseases as well as the potential for cannabinoid-directed drugs to be used as therapeutics for the treatment of cardiovascular disease. This review summarizes our current understanding of the role of cannabinoid receptors in the pathophysiology of atherosclerosis and myocardial ischemia and explores their use as therapeutic targets in the treatment of ischemic heart disease. Endocannabinoids are elevated in patients with atherosclerosis, and activation of cannabinoid type 1 receptors (CB1Rs) generally leads to an enhancement of plaque formation and atherosclerosis. In contrast, selective activation of cannabinoid type 2 receptors (CB2Rs) appears to exert protective effects against atherosclerosis. Endocannabinoid signaling is also activated by myocardial ischemia. CB2R signaling appears to protect the heart from ischemic injury, whereas the role of CB1R in ischemic injury is less clear. This narrative review serves to summarize current research on the role of cannabinoid signaling in cardiovascular function with the goal of identifying critical knowledge gaps and future studies to address those gaps in a way that facilitates the development of new treatments and better cardiovascular health. SIGNIFICANCE STATEMENT: Cardiovascular diseases, including atherosclerosis and myocardial infarction, are a leading cause of death. Cannabinoid drugs have well known acute effects on cardiovascular function, including tachycardia and orthostatic hypotension. The recent legalization of marijuana and cannabinoids for both medical and recreational use has dramatically increased their prevalence of use. This narrative review on the role of cannabinoid signaling in cardiovascular disease contributes to a better understanding of this topic by integrating current knowledge and identifying critical gaps.

Assessing the causal effect of genetically predicted metabolites and metabolic pathways on stroke

BACKGROUND

Stroke is a common neurological disorder that disproportionately affects middle-aged and elderly individuals, leading to significant disability and mortality. Recently, human blood metabolites have been discovered to be useful in unraveling the underlying biological mechanisms of neurological disorders. Therefore, we aimed to evaluate the causal relationship between human blood metabolites and susceptibility to stroke.

METHODS

Summary data from genome-wide association studies (GWASs) of serum metabolites and stroke and its subtypes were obtained separately. A total of 486 serum metabolites were used as the exposure. Simultaneously, 11 different stroke phenotypes were set as the outcomes, including any stroke (AS), any ischemic stroke (AIS), large artery stroke (LAS), cardioembolic stroke (CES), small vessel stroke (SVS), lacunar stroke (LS), white matter hyperintensities (WMH), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), transient ischemic attack (TIA), and brain microbleeds (BMB). A two-sample Mendelian randomization (MR) study was conducted to investigate the causal effects of serum metabolites on stroke and its subtypes. The inverse variance-weighted MR analyses were conducted as causal estimates, accompanied by a series of sensitivity analyses to evaluate the robustness of the results. Furthermore, a reverse MR analysis was conducted to assess the potential for reverse causation. Additionally, metabolic pathway analysis was performed using the web-based MetOrigin.

RESULTS

After correcting for the false discovery rate (FDR), MR analysis results revealed remarkable causative associations with 25 metabolites. Further sensitivity analyses confirmed that only four causative associations involving three specific metabolites passed all sensitivity tests, namely ADpSGEGDFXAEGGGVR* for AS (OR: 1.599, 95% CI 1.283-1.993, p = 2.92 × 10-5) and AIS (OR: 1.776, 95% CI 1.380-2.285, p = 8.05 × 10-6), 1-linoleoylglycerophosph-oethanolamine* for LAS (OR: 0.198, 95% CI 0.091-0.428, p = 3.92 × 10-5), and gamma-glutamylmethionine* for SAH (OR: 3.251, 95% CI 1.876-5.635, p = 2.66 × 10-5), thereby demonstrating a high degree of stability. Moreover, eight causative associations involving seven other metabolites passed both sensitivity tests and were considered robust. The association result of one metabolite (glutamate for LAS) was considered non-robust. As for the remaining metabolites, we speculate that they may potentially possess underlying causal relationships. Notably, no common metabolites emerged from the reverse MR analysis. Moreover, after FDR correction, metabolic pathway analysis identified 40 significant pathways across 11 stroke phenotypes.

CONCLUSIONS

The identified metabolites and their associated metabolic pathways are promising circulating metabolic biomarkers, holding potential for their application in stroke screening and preventive strategies within clinical settings.

Risky drinking and other drug use in adults with chronic conditions in the United States: differential associations by race/ethnicity

Co-use of multiple drugs may prolong or increase heavy drinking, even for individuals with health conditions adversely affected by it. Patterns of alcohol and drug use may vary across racial/ethnic groups, with differential implications for health. This study examines racial/ethnic differences in the associations between risky drinking and other drug use in adults with diabetes, hypertension, heart disease, or cancer. Multiple logistic regression modeling, stratified by condition, was performed using a nationally representative sample of adults drawn from the 2015 to 2019 National Survey on Drug and Health. The outcome was risky drinking (consuming more than 7/14 drinks weekly). Other drugs considered were tobacco, marijuana, illicit drugs, and non-medical prescription drugs. Covariates included age, sex, education, income, marital/cohabitation status, health insurance coverage, and self-rated health status. Each drug category was positively associated with risky drinking across all four conditions. Racial/ethnic minority adults were less likely than White adults to engage in risky drinking, with this pattern most consistent for those with hypertension. Other drug use in minority adults (i.e. tobacco and illicit drug use in Black and Hispanic adults, and marijuana and prescription drug use in Asian adults) was associated with disproportionately greater odds of risky drinking compared with White adults. This pattern was more prominent for those with a heart condition, and not found for those with cancer. Future interventions might address co-use of alcohol and other drugs in adults with chronic conditions, with special attention to racial/ethnic minority adults.

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.

Causal relationship between cannabis use and cancer: a genetically informed perspective

PURPOSE

Cannabis use is increasing legally worldwide, while its impact on cancer risk is unclear. This study was performed to investigate the relationship between cannabis use and the risk of several types of cancer.

METHODS

We conducted a two-sample Mendelian randomization (MR) study to explore the causality of cannabis use on 9 site-specific types of cancer including breast cancer, cervical cancer, melanoma, colorectal cancer, laryngeal cancer, oral cancer, oropharyngeal cancer, esophageal cancer, and glioma. Genome-wide significant genetic instruments (P < 5E-06) for cannabis use were extracted from a large-scale genome-wide association meta-analysis of European ancestry, whereas cancer genetic instruments were extracted from the UK Biobank (UKB) cohort and GliomaScan consortium in the OpenGWAS database. The inverse-variance weighted (IVW) was considered the main method for MR analysis, and sensitivity analyses including MR-Egger, weighted median, MR pleiotropy residual sum, and outlier test (MR-PRESSO) were conducted to evaluate the robustness of the results.

RESULTS

Cannabis use was a significant promoting factor for cervical cancer (OR = 1.001265, 95% CI 1.000375-1.002155, P = 0.0053). And we also detected suggestive evidence of the causality of cannabis use on laryngeal cancer (OR = 1.000350, 95% CI 1.000027-1.000672, P = 0.0336) and breast cancer (OR = 1.003741, 95% CI 1.000052-1.007442, P = 0.0467). No evidence of a causal association of cannabis use with other site-specific types of cancer was detected. Additionally, no pleiotropy or heterogeneity was found in the sensitivity analysis.

CONCLUSION

This study indicates a causative association of cannabis use on cervical cancer, while cannabis use may increase the odds of breast cancer and laryngeal cancer, which require further evaluation in large-scale population-based studies.

Association between lifetime cannabis use and arterial stiffness in a middle-aged general population

BACKGROUND

No studies have investigated the association between arterial stiffness index (ASI) and cannabis use. The purpose of this study is to examine sex-stratified associations of cannabis use and ASI levels in a middle-aged general population.

METHODS

Cannabis use of 46 219 volunteers of the middle-aged UK Biobank population was assessed by questionnaire and investigates several aspects of cannabis use (lifetime, frequency and current status). Associations between cannabis use and ASI were estimated using sex multiple linear regressions. Covariates were tobacco status, diabetes dyslipidaemia, alcohol status, BMI categories, hypertension, mean blood pressure and heart rate.

RESULTS

Men presented higher ASI levels compared with women (respectively, 9.826 vs. 8.578 m/s, P < 0.001), a higher heavy lifetime cannabis users (4.0 vs. 1.9%, P < 0.001), higher current cannabis users (3.1 vs. 1.7%, P < 0.001), higher current smokers (8.4 vs. 5.8%, P < 0.001) and higher alcohol users (95.6 vs. 93.4%, P < 0.001). After adjustment for all covariates in sex models, heavy lifetime cannabis users were associated with higher ASI levels in men [b = 0.19, 95% confidence interval (0.02; 0.35)] but not in women [b = -0.02 (-0.23; 0.19)]. Current cannabis users were associated with higher ASI levels in men [b = 0.17 (0.01; 0.32)] but not in women [b = -0.01 (-0.20; 0.18)] and among cannabis users, every day frequency was associated with increased ASI levels in men [b = 0.29 (0.07; 0.51)] but not in women [b = 0.10 (-0.17; 0.37)].

CONCLUSION

The observed association between cannabis use and ASI could participate in accurate and appropriate cardiovascular risk reduction strategies among cannabis users.

Association of cannabis use disorder with cardiovascular diseases: A two-sample Mendelian randomization study

Background

The use of cannabis has increased globally due to more regions decriminalizing marijuana use for therapeutic and recreational aims. Several observational studies have revealed that cannabis use is associated with an increased risk of adverse cardiovascular pathologies and diseases. Nevertheless, the causal associations between cannabis use and cardiovascular diseases remain unclear. Hence, we performed single-variable and multivariable Mendelian randomization (MR) to evaluate the association between cannabis use disorder and various cardiovascular diseases.

Materials and methods

Summary statistics were collected from the largest-to-date genome-wide association studies (GWAS) of cannabis use disorder. The 12 SNPs for cannabis use disorder were used as instrumental variables in this study. MR estimates were pooled using a random-effects inverse-variance weighted (IVW) method. Simple median and weighted median methods were conducted as sensitivity analyses.

Results

The genetic liability to cannabis use disorder was associated with an augmented risk of coronary artery disease, myocardial infarction, atrial fibrillation, heart failure, deep venous thrombosis, pulmonary embolism, and stroke. Except for stroke, the results were inconsistent in the sensitivity analyses. The overall patterns for the associations of cannabis use disorder with atrial fibrillation, heart failure, pulmonary embolism and stroke remained in multivariable MR analyses adjusting for potential mediators, including smoking, alcohol, body mass index, blood lipid, type 2 diabetes, hypertension, and depression. However, the association with coronary artery disease, myocardial infarction, and deep venous thrombosis did not persist in multivariable MR analyses. Mediation analysis demonstrated that smoking, body mass index, low-density lipoprotein, hypertension, and depression have more significant mediation effects, which suggests that these factors partly mediate the link from cannabis use disorder to coronary artery disease, myocardial infarction, and deep venous thrombosis.

Conclusion

The genetic liability to cannabis use disorder was associated with a higher risk of atrial fibrillation, heart failure, pulmonary embolism, and stroke. The evidence for the association between cannabis use disorder, coronary artery disease, myocardial infarction, and deep venous thrombosis was weak. Hence, future use of cannabis for therapeutic and recreational aims should consider its potential impact on cardiovascular diseases.

Considerations for Cannabinoids in Perioperative Care by Anesthesiologists

Increased usage of recreational and medically indicated cannabinoid compounds has been an undeniable reality for anesthesiologists in recent years. These compounds’ complicated pharmacology, composition, and biological effects result in challenging issues for anesthesiologists during different phases of perioperative care. Here, we review the existing formulation of cannabinoids and their biological activity to put them into the context of the anesthesia plan execution. Perioperative considerations should include a way to gauge the patient’s intake of cannabinoids, the ability to gain consent properly, and vigilance to the increased risk of pulmonary and airway problems. Intraoperative management in individuals with cannabinoid use is complicated by the effects cannabinoids have on general anesthetics and depth of anesthesia monitoring while simultaneously increasing the potential occurrence of intraoperative hemodynamic instability. Postoperative planning should involve higher vigilance to the risk of postoperative strokes and acute coronary syndromes. However, most of the data are not up to date, rending definite conclusions on the importance of perioperative cannabinoid intake on anesthesia management difficult.