From the Guidelines
Cocaine and methamphetamine are the primary illicit drugs that can cause cardiomyopathy, leading to damage to the heart muscle and affecting its ability to pump blood effectively.
Illicit Drugs Associated with Cardiomyopathy
- Cocaine: causes direct toxicity to heart cells, coronary artery spasm, accelerated atherosclerosis, and increased oxygen demand that can lead to dilated cardiomyopathy 1
- Methamphetamine: damages the heart through catecholamine excess, causing hypertrophy, fibrosis, and inflammation, and can result in decreased myocardial perfusion and abnormal ECG findings 1 Other illicit drugs, such as MDMA (ecstasy), heroin, and opioids, may also cause cardiomyopathy through various mechanisms, including hypoxic damage, contaminants, and catecholamine excess.
Key Mechanisms and Risks
- Catecholamine excess: leads to hypertrophy, fibrosis, and inflammation in the heart
- Coronary artery spasm: increases oxygen demand and can lead to myocardial ischemia and infarction
- Direct toxicity: damages heart cells and leads to cardiomyopathy The risk of developing drug-induced cardiomyopathy increases with frequency of use, higher doses, and longer duration of exposure, while polysubstance use compounds these risks.
Clinical Implications
Early cessation of drug use is essential for preventing progression of cardiac damage. General principles for risk stratification of patients with chest pain apply to patients with cocaine or methamphetamine use 1.
From the FDA Drug Label
OVERDOSAGE Clinical Effects of Overdose Overdose of CNS stimulants is characterized by the following sympathomimetic effects: • Cardiovascular effects including tachyarrhythmias, and hypertension or hypotension. Vasospasm, myocardial infarction, or aortic dissection may precipitate sudden cardiac death. Takotsubo cardiomyopathy may develop Risks to Patients with Serious Cardiac Disease Sudden death has been reported in patients with structural cardiac abnormalities or other serious cardiac disease who are treated with CNS stimulants at the recommended ADHD dosages Avoid methamphetamine use in patients with known structural cardiac abnormalities, cardiomyopathy, serious cardiac arrhythmia, coronary artery disease, or other serious cardiac disease.
Methamphetamine can cause cardiomyopathy, specifically Takotsubo cardiomyopathy 2. Additionally, patients with pre-existing cardiomyopathy should avoid using methamphetamine due to the risk of sudden death 2.
From the Research
Illicit Drugs Associated with Cardiomyopathy
The following illicit drugs have been linked to cardiomyopathy:
- Methamphetamine: Methamphetamine-associated cardiomyopathy (MAC) has been increasingly reported, with proposed mechanisms including excessive sympathetic stimulation and increased myocardial oxygen consumption 3.
- Cocaine: Cocaine abuse has been associated with the development of dilated cardiomyopathy, with clinical features including hypertension, tachycardia, and systolic murmur 4, 5, 6. The exact incidence of cocaine-related cardiomyopathy is unknown and likely underreported.
- Metamfetamines: Catecholamine-mediated toxicity is the probable cause of metamfetamine-induced cardiomyopathy, with a possible role for genetic susceptibility 7.
Key Findings
- Methamphetamine and cocaine are the most commonly reported illicit substances associated with cardiomyopathy.
- The clinical course of cardiomyopathy caused by these substances can be abrupt and similar to other types of cardiomyopathy.
- Management of cardiomyopathy caused by illicit substance abuse is similar to other forms of cardiomyopathy, but beta-blockers should be avoided in the case of cocaine-induced cardiomyopathy.
- Myocardial dysfunction caused by cocaine ingestion can be reversible with abstention from further cocaine use 4.