Recreational Drug Use More Common in Intensive Cardiac Care Than Many Admit

Many recreational drug users suffering acute cardiovascular events ended up in cardiac intensive care units (ICUs) without disclosing their drug use, according to the ADDICT-ICCU study conducted across France.

The incidence of a positive drug screen was 11% among 1,499 consecutive patients admitted for acute cardiovascular events, with systematic urine testing revealing use of cannabis (9.1%), opioids (2.1%), cocaine (1.7%), amphetamines (0.7%), and MDMA (0.6%).

People with positive drug screens subsequently had a higher risk of in-hospital major adverse events (13% vs 3% for non-users, adjusted OR 8.84, 95% CI 4.68-16.7), driven by increased hemodynamic shock, reported Patrick Henry, MD, PhD, of Assistance Publique-Hopitaux de Paris, and colleagues in Heart.

"These current findings can be explained by several types of sympathomimetic effects of recreational drugs, which can increase blood pressure, heart rate, temperature, and consequently myocardial oxygen demand," they wrote.

Furthermore, they noted that 57% of people screening positive had admitted to recreational drug use during the admission interview.

"While the current guidelines recommend only a declarative survey to investigate recreational drug use, these findings suggest the potential value of urine screening in selected patients with acute cardiovascular events to improve risk stratification in ICCUs [intensive cardiac care units]," Henry and colleagues suggested.

They cited evidence showing that recent use of cannabis or cocaine in patients with myocardial infarction is associated with worse outcomes in the long run.

Moreover, it is possible that a positive test result might help with diagnosing a person's acute illness or otherwise help clinical management, pointed out R. Andrew Archbold, MD, and colleagues of St. Bartholomew's Hospital in London.

However, in an accompanying editorial, they cautioned that "there is a considerable way to go" before routine drug screening can be recommended, even if systematic screening is more reliable than relying on patient reports.

"No data were presented concerning the cost of screening, the benefits arising from screening, or its cost-effectiveness. Furthermore, screening for recreational drug use raises important questions concerning patient confidentiality and the potential for discrimination in how targeted screening might be applied," the trio warned.

Henry's group noted that the prevalence of recreational drug use is estimated to be 16% in the U.S., which is higher than the 11.4% in France, where the study was conducted.

The 1,499 ADDICT-ICCU participants (average age 63, 70% men) had been admitted to ICUs in 39 French hospitals during a 2-week period in 2021. They underwent prospective urinary testing as soon as possible, at most within 2 hours of admission to the cardiac ICU.

Just over half of patients were there for acute coronary syndromes (50.8%), while the rest represented a mix of acute heart failure, severe cardiac conduction abnormalities, arrhythmias, pulmonary embolism, myocarditis, chest pain without an identified cardiovascular cause, or other cardiovascular or non-cardiovascular diagnoses.

Of the positive drug screens, 72% indicated a single drug and 28% indicated multiple drugs. Multiple drug detection was tied to an especially high risk of in-hospital adverse events (OR 12.7, 95% CI 4.80-35.6).

Cannabis, cocaine, and MDMA were each independently associated with poor outcomes.

Notably, one in three people under 40 years old had recreational drugs detected by Henry and colleagues.

Indeed, recreational substance use -- including tobacco, alcohol, cocaine, amphetamines, and cannabis -- has been associated with early-onset atherosclerotic cardiovascular disease, with events occurring before age 55 for men and 65 for women.

The current study found that recreational drug users tended to be disproportionately younger, more likely to be current smokers and HIV positive, and had a lower burden of comorbidities such as diabetes and high blood pressure.

That the researchers could not detect recreational drug use in the days or weeks before hospitalization was a major limitation of the study, as was the confinement of the study period to a narrow window in the calendar year, Henry and colleagues acknowledged.

"Larger studies which assess rates of recreational drug use and clinical outcomes in patients who present to hospital with acute cardiovascular conditions, and in the general population, would be welcomed," Archbold and colleagues noted.

"These would help to provide more reliable estimates of the prevalence of recreational drug use, the etiological relationship between recreational drug use and cardiovascular conditions leading to hospital admission, and the impact of recreational drug use on clinical outcomes according to individual drug types," they wrote.

Comment