Recreational Drug Use May Predict Poor Outcomes in Cardiac Intensive Care

Professor Patrick Henry

Credit: L'hôpital Lariboisière

New research detected recreational drug use in more than 1 in 10 patients admitted to cardiac intensive care units across France, indicating drug use as a robust independent predictor of in-hospital major adverse events (MAEs).¹

The analysis of the Addiction In Intensive Cardiac Care Units (ADDICT-ICCU) study showed recreational drug users were approximately nine times as likely to die or require emergency interventions compared with other hospitalized patients and 12 times more likely if they used more than one drug.

“Using a systematic urine assay, our study is the first to suggest a poorer in-hospital prognosis in those with detected recreational drugs in all consecutive patients admitted to ICCUs, which shows a potential interest in improving risk stratification of these patients,” wrote the investigative team, led by Professor Patrick Henry, Department of Cardiology, Hôpital Lariboisière, Assistance Publique - Hopitaux de Paris, Université Paris Cité.

Data suggests an estimated 275 million people globally used recreational drugs in 2022, an 22% increase in the figure since 2010. Drugs, including cannabis, cocaine, 3,4-methylenedioxymethamphetamine (MDMA), amphetamines, heroin, and other opioids were shown to be the most used substances.

The chronic recreational use of these substances is a risk factor for various acute cardiovascular events, including sudden cardiac death, acute heart failure, thromboembolic events, and cardiac arrhythmia. Literature has reported substance use in patients with myocardial infarction is associated with worse outcomes over time, but these studies were often retrospective or post hoc analyses without systematic screening and with a risk of recall bias.

Current guidelines recommend only a declarative survey to investigate recreational drug use and not a systematic urine or plasma screening. As a result, the prevalence of drug use in patients hospitalized in ICCUs and their effect on short-term cardiovascular outcomes is still unknown.

The ADDICT-ICU study was designed to prospectively assess the prevalence of recreational drug use and its association with the occurrence of in-hospital adverse events. The prospective, observational study analyzed the urine samples of all consecutive patients ≥18 years old admitted to ICCUs across a 2-week period in April 2021 in France.

For the analysis, clinical outcomes included in-hospital MAEs, consisting of in-hospital death, resuscitated cardiac arrest, and hemodynamic shock requiring medical or mechanical hemodynamic support.

Within the study period, a total of 1904 patients were admitted to ICCUs in the 39 participating centers. After applying exclusion criteria, 1499 patients (95.2%) were screened using a urine drug assay (mean age, 63 years; 70% male).

Of the 1499 screened patients, 161 (11%) had a positive urine test for ≥1 recreational drug, including cannabis (9.1%), opioids (2.1%), cocaine (1.7%), amphetamines (0.7%), and MDMA (0.6%). A total of 116 (72.0%) patients had used a single drug and 45 (28.0%) had used multiple recreational drugs. However, of the recreational drug users, only 91 (57%) declared recreational drug use during the admission interview by physicians.

During hospitalization, there were 61 in-hospital MAEs (4.3%), including 25 (1.8%) in-hospital deaths, 10 (0.7%) cardiac arrests, and 26 (1.8%) hemodynamic shocks requiring hemodynamic support.

In multivariable analysis, the detection of recreational drug use was independently associated with in-hospital MAEs after adjusting for comorbidities (odds ratio [OR], 8.84; 95% CI, 4.68 - 16.7; P <.001). Compared with non-using heart patients, those who used recreational drugs showed a higher MAE rate, including hemodynamic shock and cardiac arrest, while in the hospital (13% vs. 3%; P <.001).

Further analyses revealed cannabis (P <.001), cocaine (P = .004), and MDMA (P <.001), assessed separately, was significantly associated with in-hospital MAEs. The detection of multiple recreational drugs was associated with a higher rate of in-hospital MAEs (OR, 12.7; 95% CI, 4.80 - 35.6; P <.001), compared with a single drug (OR, 6.31; 95% CI, 3.01 - 12.8; P <.001).

Investigators urged caution in their conclusion, indicating the limited number of events and short study period as potential roadblocks to clinical interpretation.

“Although the strong associations between the use of recreational drugs and the occurrence of MAEs suggest an important prognostic role, the limited number of events requires caution in the clinical interpretation of these findings,” investigators wrote.²

References

1. Pezel T, Dillinger J, Trimaille A, et al. Prevalence and impact of recreational drug use in patients with acute cardiovascular eventsHeart Published Online First: 15 August 2023. doi: 10.1136/heartjnl-2023-322520
2. bmj_company (2023) Recreational drugs detected in more than 1 in 10 cardiac intensive care patients, EurekAlert! Available at: https://www.eurekalert.org/news-releases/998379 (Accessed: 16 August 2023).