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Illicit Drugs: A Crisis of the Heart

Daniel F. Pauly, MD, PhDFACP, FACC, FAHA

Chief of CardiologyProfessor of Medicine and Professor of Biomedical and Health Informatics

University of Missouri Kansas City School of Medicine

Illicit Drugs: A Crisis of the Heart

No Disclosures

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Learning Objectives

• Understand the contribution of opiates to recurrent endocarditis

• Recognize the contribution of cocaine to progressive myocardial ischemia

• Be informed on the pathways by which methamphetamine leads to cardiomyopathy and heart failure

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Opiate and Opioid• Opiate

– Derived from poppy plant• Morphine• Codeine• Heroin

• Opioid– Synthetic agents

• Fentanyl• Hydrocodone• Hydromorphone• Meperidine• Methadone• Oxycodone• Tramadol

Opiates and Opioids

• Bind to the μ (mu) receptor– G-protein receptors in central nervous system and

elsewhere• Blocks pain signals• Reduces perception of pain• Releases dopamine• Creates sense of well-being and euphoria

– Strong sensation of reward– Withdrawal sensation lasts for months to year

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Tricuspid valve endocarditis in the era of opioid epidemic

Retrospective review of 783 surgical cases

Journal of Cardiac Surgery, Volume: 33, Issue: 5, Pages: 260-264, First published: 16 April 2018, DOI: (10.1111/jocs.13600)

Tricuspid valve endocarditis in the era of the opioid epidemic

Journal of Cardiac Surgery, Volume: 33, Issue: 5, Pages: 260-264, First published: 16 April 2018, DOI: (10.1111/jocs.13600)

• Staph aureus• Strep species• Other• Enterococcus• Culture negative• Fungal• Coag neg Staph

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• From 2010 to present the surgical volume for tricuspid endocarditis has increased 5-fold– Related to opioid epidemic

• Patients are younger and have fewer comorbidities than the general surgical population– Mortality rate > 10%– Recidivism to IV drug use is high

• Repeat endocarditis rate > 10%

Discussion

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Cocaine

• Inhibits reuptake of– Serotonin– Norepinephrine– Dopamine

Cocaine

• Coronary vasospasm• Chest pain• Myocardial infarction• Ventricular arrhythmias

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Cocaine

• Chest pain– Can reflect vasospasm– Microvascular dysfunction– Concomitant atherosclerotic disease is less

common but can occur

• ECG changes• Cardiac biomarkers

– Troponin-T

Crystal methamphetamine

• Smokable stimulant drug– Rapid release of neurotransmitters

• Dopamine• Norepinephrine• Serotonin

• Retrospective study of 590 patients– Discharged from California hospital with diangosis of

heart failure or cardiomyopathy• Excluded if known CAD or peripartum period

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Am J Cardiol. 2016;118:585-589.

Crystal methamphetamine

• Mechanism of heart failure is similar to the standard paradigm

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Cardiomyopathy-relatedHeart Failure

Pauly DF. Cardiol Clin. 2014 Feb; 32:145-9.

Binds to the Mechanochemical Domain of Myosin

S1 Domain of Myosin

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Summary• Opiates-Opioids

– Endocarditis• Staph aureus

– High rate of repeat infection

• Cocaine– Chest pain– Coronary vasospasm

• Crystal methamphetamine– Cardiomyopathy and heart failure

• Blood pressure, vasospasm, direct molecular toxicity• Typically with no atherosclerotic CAD