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Original article
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# Cannabis Use Disorder in Young Adults with Acute Myocardial Infarction: Trend Inpatient Study from 2010 to 2014 in the United States

### Abstract

#### Objective

This study determines the trend of acute myocardial infarction (AMI) in cannabis users. Demographic characteristics, hospitalization outcomes, and utilization of primary treatment modalities were evaluated in AMI inpatient population.

#### Methods

The study used data from the nationwide inpatient sample (NIS) for the years 2010-2014. We identified patients with AMI as the primary diagnosis (N = 379,843) and patients with cannabis use disorder as the secondary diagnosis. We used Pearson’s chi-square (χ2) test and independent sample t-test for measuring the categorical and continuous data, respectively.

 Variable 2010 2011 2012 2013 2014 Total P value for trend Trend direction Admission (in %) Nonelective 92.8 94.6 97.0 96.0 94.5 95.0 0.003 Increasing Elective 7.2 5.4 3.0 4.0 5.5 5.0 0.003 Decreasing Severity of illness at admission (in %) Mild 34.3 31.8 30.1 34.7 27.4 31.5 0.001 Decreasing Moderate 41.5 39.7 48.3 41.9 44.0 43.2 0.001 Increasing Severe 24.2 28.5 21.6 23.4 28.6 25.4 0.001 Increasing Treatment (in %) Angiography 22.2 22.2 22.8 24.8 22.2 22.8 0.447 Stable PTCA 51.7 51.6 49.5 49.5 49.8 50.4 0.073 Decreasing CABG 5.5 6.4 5.6 5.7 7.1 6.1 0.092 Increasing Other outcomes Mean inpatient stay (in days) 3.72 3.39 3.32 3.13 3.39 3.38 0.003 Decreasing Mean inpatient cost (in $) 62,327 62,803 62,023 67,676 72,968 65,879 0.024 Increasing In-hospital mortality (in %) 1.0 1.0 1.0 1.7 1.6 1.3 0.007 Increasing ### Discussion This study describes the analysis of CUD with AMI outcomes based on population-based hospital data over the period of 2010-2014. The study findings are supportive of what has been previously established in the literature about drug use and its direct impact on vascular function and myocardial infarction [7, 14]. The study showed a significant increase in the proportion of AMI admissions in the hospitals involving CUD as an associated risk factor. An increase in the number of visits by 32% over five years brings out an important public health implication, exaggerating the strong influence of CUD and its direct impact on AMI. These results agree with other key findings in the literature including several case reports and published articles [2, 3, 15] We consider our study to be one of the few studies in the literature to assess the relationship between AMI and CUD with the type of insurance coverage used. A previous study by Rumalla et al. that focused on recreational marijuana use and subarachnoid hemorrhage was the only study that we observed comparable to our study criteria on the type of insurance covered. Rumalla et al. observed higher cannabis use among medicaid enrollees compared to nonusers (31.1% vs. 18.3%) [16]. In our study, 37.5% of cannabis users had medicaid insurance in 2014, which indicates an important problem of insurance being a supportive factor promoting CUD and thus increasing overall hospital burden in the United States. Along with this observation, it is also important to note that the 37.5% is also attributable to an overall 70.5% increase from the years 2010 to 2014, from 21% previously. Another important finding of this study was the increase in a number of emergency visits among cannabis users. This trend was found significant, along with an indication of 68% admissions in AMI patients attributable to cannabis use. The study highlights the increase in overall healthcare costs and procedures in AMI patients pertaining to cannabis use specifically. This is mainly reflected by several important findings in our study viz. angiography being performed in 22.8% of cannabis users, 3.4 days’ mean length of stay, average hospitalization costs as much as$65,879, and above all, 60% increase in in-hospital mortality during inpatient management of AMI.

Our study also has several limitations. As this is among the pioneer studies assessing the type of insurance and its effect on AMI admissions, we did not have enough supporting literature to back up our findings. However, our study uses a stronger established dataset and high internal validity to report the findings, and thus sets a strong foundation with implications on the need for further research to warrant our findings. The second limitation was that we could not look at re-admission status for the participants, and that is because of the nature of the database. The database, however being a strong population-based registry with high generalizability sets a benchmark for these types of further studies, overweighs the importance of characteristic findings compared to limitations. However, this study had several strengths. First, our study exhibits a strong external validity in the form of generalizability of the results. Our second strength is that to our knowledge, this is the first study that assesses the healthcare insurance aspect and its impact on CUD and AMI admissions. The results of the study show an inadvertent increase in healthcare costs, mainly attributed to drug use and preventable risk factors that can be avoided. The final strength of the study is how the study avoids reporting bias, due to the use of the NIS dataset and its unique characteristic of data being coded independently of the practitioner.

### Conclusions

The prevalence of AMI in inpatient US population is decreasing, but the number of cases of AMI in cannabis users is rising. A linear increasing trend of AMI among cannabis users is seen in females, native Americans or Asians and those covered by medicaid. Due to the risk of AMI, as seen in numerous case reports, the trend of emergency admission and severe morbidity due to AMI in cannabis users is also increasing. Also, there was a spike seen in the utilization of more invasive procedures like CABG which may have indirectly increased hospitalization cost per inpatient management for AMI in cannabis users. Despite all these measures, the in-hospital mortality had risen tremendously over the last few years. It is imperative to know that chronic cannabis worsens the outcomes in AMI patients, and more clinical studies are needed to show the association of episodic use in cannabis abusers and AMI. Also, large-scale epidemiological studies are required to measure the prospective risks involved in cannabis abusers due to increasing cannabis or marijuana use for therapeutic purposes after medical marijuana laws are passed in the United States.

### References

1. Goyal H, Awad HH, Ghali JK: Role of cannabis in cardiovascular disorders. J Thorac Dis. 2017, 9:2079-2092. 10.21037/jtd.2017.06.104
2. Kocabay G, Yildiz M, Duran NE, Ozkan M: Acute inferior myocardial infarction due to cannabis smoking in a young man. J Cardiovasc Med (Hagerstown). 2009, 10:669-670. 10.2459/JCM.0b013e32832bcfbe
3. Cappelli F, Lazzeri C, Gensini GF, Valente S: Cannabis: a trigger for acute myocardial infarction? A case report. J Cardiovasc Med (Hagerstown). 2008, 9:725-728. 10.2459/JCM.0b013e3282f2cd0d
4. Hodcroft CJ, Rossiter MC, Buch AN: Cannabis-associated myocardial infarction in a young man with normal coronary arteries. J Emerg Med. 2014, 47:277-281. 10.1016/j.jemermed.2013.11.077
5. Kotsalou I, Georgoulias P, Karydas I, et al.: A rare case of myocardial infarction and ischemia in a cannabis-addicted patient. Clin Nucl Med. 2007, 32:130-131. 10.1097/01.rlu.0000252218.04088.ff
6. Mehta JJ, Mahendran AK, Bajaj RK, Doshi AR: Myocardial ischemia with cannabinoid use in an adolescent. Cureus. 2017, 9:e1899. 10.7759/cureus.1899
7. Mittleman MA, Lewis RA, Maclure M, Sherwood JB, Muller JE: Triggering myocardial infarction by marijuana. Circulation. 2001, 103:2805-2809.
8. Aryana A, Williams MA: Marijuana as a trigger of cardiovascular events: speculation or scientific certainty?. Int J Cardiol. 2007, 118:141-144. 10.1016/j.ijcard.2006.08.001
9. Aronow WS, Cassidy J: Effect of marijuana and placebo-marijuana smoking on angina pectoris. N Engl J Med. 1974, 291:65-67. 10.1056/NEJM197407112910203
10. Overview of the national (nationwide) inpatient sample (NIS). (2018). Accessed: August 9, 2018: https://www.hcup-us.ahrq.gov/nisoverview.jsp.
11. Clinical classifications software (CCS) for ICD-9-CM. (2017). Accessed: August 9, 2018: https://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp.
12. Patel RS, Patel P, Shah K, Kaur M, Mansuri Z, Makani R: Is cannabis use associated with the worst inpatient outcomes in attention deficit hyperactivity disorder adolescents?. Cureus. 2018, 10:e2033. 10.7759/cureus.2033
13. IBM SPSS statistics. (2013). Accessed: August 9, 2018: https://www.ibm.com/products/spss-statistics.
14. Wang X, Derakhshandeh R, Liu J, et al.: One minute of marijuana secondhand smoke exposure substantially impairs vascular endothelial function. J Am Heart Assoc. 2016, 5:e003858. 10.1161/JAHA.116.003858
15. Beck CA, Southern DA, Saitz R, Knudtson ML, Ghali WA: Alcohol and drug use disorders among patients with myocardial infarction: associations with disparities in care and mortality. PLoS One. 2013, 8:e66551. 10.1371/journal.pone.0066551
16. Rumalla K, Reddy AY, Mittal MK: Association of recreational marijuana use with aneurysmal subarachnoid hemorrhage. J Stroke Cerebrovasc Dis. 2016, 25:452-460. 10.1016/j.jstrokecerebrovasdis.2015.10.019

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###### Ethics Statement and Conflict of Interest Disclosures

Human subjects: Consent was obtained by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Original article
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