Tobacco, Cannabis, Vaping, Alcohol, Cocaine, Meth and the Heart

Question 1

In what ways does tobacco impact one’s lipids?

Answer 1

Elevated triglycerides, decreased HDL

Question 2

Be able to explain the various ways in which nicotine and carbon monoxide impact
cardiovascular function.

Answer 2

Carbon Monoxide, Nicotine:
o widespread tissue hypoxia, endothelial damage, plaque build-up
o Thickening/narrowing of blood vessels and increased build-up of
atherosclerotic plaque
o ARIC Study showed 50% increase in Intima Medial Thickness in smokers,
20% increase in secondhand smoke exposure

Question 3

How does tobacco use increase risk for formation of blood clots?

Answer 3

Clot risk: endothelial injury → increase platelet aggregation causing
increased clotting likelihood

Question 4

How does tobacco use increase risk for an abdominal aortic aneurysm?

Answer 4

AAA Risk: Endothelial damage, destruction of lamellar matrix (COPD) due to
inflammatory state

Question 5

What is Buerger’s disease (thromboangiitis obliterans)?

Answer 5

Buerger’s Disease:
o increased inflammation?
o Unclear pathophysiology but a very strong correlation

Question 6

Does secondhand smoke exposure increase risk for ASCVD?

Answer 6

Yes

Risk of heart disease can increase by ~25-30%, though the data is variable

Question 7

How long does it take after smoking cessation for risk of major adverse cardiovascular
events to return to baseline risk similar to nonsmokers?

Answer 7

Risk of Major Adverse Cardiac Events (MACE) is significantly lower 5 years after
cessation, but it may take up to 10 -15 years to return to baseline risk of never
smokers

Question 8

What are the types of cannabis that are FDA approved for patient use? What are the
indications for their use?

Answer 8

Cannabidiol: Used for seizures

Dronabinol: Used for chemo associated N/V and HIV associated anorexia

Nabilone: Used for chemo associated N/V

Question 9

What component of cannabis is responsible for psychoactive effects?

Answer 9

THC

Question 10

What are the two most common strains of cannabis? Which one is more stimulating
versus more sedating?

Answer 10

Cannabis sativa - uplifting

Cannabis indica - sedative

Question 11

What receptor is responsible for many of cannabis’ effects on the body?

Answer 11

Effects are widespread through the endocannabinoid system in several organ
systems in the body – most densely populated receptor is the CB1 receptor
which is responsible for many cannabis effects

Question 12

When inhaling cannabis, what other substances are also inhaled in the process?

Answer 12

3 fold increase in amount of tar inhaled

Over 50 known carcinogens have been identified in cannabis smoke

Question 13

What are the limitations with research on cannabis?

Answer 13

o Schedule I Drug federally → difficult to proceed with research
o Potency / Lack of standardization
o Route of administration is variable.
o Smoking vs vaping – which is worse?
o Concomitant tobacco use conflicts data as well

Question 14

What is the typical use pattern of cannabis versus tobacco?

Answer 14

Cannabis: larger puff and inhaled volume, longer breath-hold

Tobacco: more frequent puffs

Question 15

What is the link between cannabis use and increased risk for CAD?

Answer 15

CAD: Decreased exercise tolerance until angina after cannabis use compared
to tobacco, chronic use may have less effects however. Many case reports of
cannabis use within 1- 24hr of myocardial infarction (likely to be male, obese,
concomitant tobacco users)
o Related to increased HR and BP due to elevated SNS activation,
increased oxygen demands

Question 16

What is the pathophysiology of dysrhythmias linked with cannabis use?

Answer 16

Arrythmias (3%): a-fib/flutter, AV block, sick sinus syndrome, VT. A-fib is
most common.
▪ Related to increased catecholamine release

Question 17

What are some potential metabolic effects from cannabis use?

Answer 17

Small RCTs demonstrate cannabis use may decrease LDL levels and possibly
contribute to weight loss, may also improve pancreatic B-cell function and
decrease fasting plasma glucose

Question 18

How have the trends in cannabis use changed with the COVID-19 pandemic?

Answer 18

40% of medical cannabis users increased uses since the pandemic, most
commonly for mental health concerns
• 16% of patients switched to non-smoking forms due to concern of acquiring
COVID-19

Question 19

Are e-cigarettes effective for smoking cessation? Should we be recommending ecigarettes as a method for smoking cessation?

Answer 19

Recent survey study showed up to 56% of e-cigarette users reported using them to quit or reduce cigarette use.

There are 2 RCTs that evaluated the effect of e-cigarettes on smoking abstinence in adults with mixed results.

Question 20

What are the trends of e-cigarette users transitioning to smoking cigarettes and vice
versa?

Answer 20

Starting with E-Cigarette use: E-cigarette users are more likely to progress to
regular cigarette users
o Switching to E-Cigarettes: may have less chronic health effects, however, may
also defer patients from FDA approved NRT

Question 21

What are the components of e-cigarettes? What are constituents in e-cigarette
cartridges?

Answer 21

Nicotine: Common content ranges from 6 mg/mL, 12 mg/mL, 18 mg/mL, 24
mg/mL. Can be as low as nicotine-free and as high as 36 mg/mL
o Propylene Glycol/glycerol: Added as humectant
o Flavor: >7000 flavors available, makes more attractive to youth
o Other?: tin, lead, nickel, chromium, manganese, arsenic?!, VOCs,

Question 22

What are the concerns of e-cigarette use?

Answer 22

Other cancer-causing ingredients
o Polypropylene glycol (when heated → formaldehyde)
o Diacetyl (flavoring agent → “popcorn lung”)
o 5 minutes of use → significant increase air flow resistance
o Unknown long-term risks of many of the toxins present
o Strong evidence that frequent low or short-term levels of exposure to ultrafine
particles (tobacco smoke or air pollution) can increase the risk of cardiovascular
and respiratory disease and death

Question 23

How might Vaping Associated Lung Injuries present in patients?

Answer 23

An acute lung injury associated with a number of different disease patterns
(pneumonia, diffuse alveolar damage, ARDS, diffuse alveolar hemorrhage,
pneumonitis

Question 24

What component in vapes is believed to be the cause of Vaping Associated Lung
Injuries? What types of vaping pens was this component found in?

Answer 24

Vitamin E acetate was strongest contributor in bronchoalveolar lavage (BAL)
fluids. This was found in 20 of 20 samples in 2019 THC vaping products, it was
found in 0 of 10 samples in 2018. It has since been banned

Question 25

What risk factors were associated with Vaping Associated Lung Injuries?

Answer 25

2807 hospitalized cases as of February 2020, and 68 deaths, of the deaths: o 9x as likely to have COPD, more than twice as likely to have asthma history or tobacco use history o 5x as likely to have CVD compared to those who survived o Death from EVALI received dx from ARDS (CVD and COPD not known risk factors for this) o Median age of survival was 23 years, median age of death was 45 years

Question 26

How might e-cigarettes have an impact on cardiovascular health?

Answer 26

Studies are limited but show: o Heart rate variability shifted toward sympathetic predominance o Increased markers of oxidative stress o Decreased arterial compliance o Increased odds of CAD/MI compared with non-smokers, decreased odds compared with smokers • Effects of e-cigarettes are not as pronounced as tobacco cigarettes

Question 27

What are the trends of vape use during the COVID-19 pandemic?

Answer 27

• Study from August of 2020 in Journal of Adolescent Health o Young adults were 6.8x more likely to develop COVID-19 if using ecigarettes o 5x more likely to develop symptoms of COVID-19 (cough, fever, SOB) compared to non-smokers o Controlled for: age, sex, LGBTQ status, race/ethnicity, LGBTQ status, mother’s level of education, BMI, compliance with COVID-19 precautions and rate of COVID-19 dx in states

Question 28

What are the various effects of alcohol on the cardiovascular system? How does this manifest clinically?

Answer 28

Binge drinking and the consumption of excessive amounts of alcohol increase risk for cardiovascular disease: o At substantial amounts may cause: ▪ Systolic and/or diastolic dysfunction: • Even small amounts of alcohol are associated with an acute worsening of diastolic function • Ethanol may induce asymptomatic left ventricular systolic dysfunction even when it is ingested by healthy individuals in relatively small quantities “social” drinkers ▪ HTN ▪ Dysrhythmias ▪ Sudden cardiac death

Question 29

How does alcohol impact the heart (what is the pathophysiology)? Is the damage reversible?

Answer 29

Ethanol may cause myocardial damage via several mechanisms: o Ethanol and metabolites acetaldehyde and acetate may exert a direct toxic effect on the myocardium o Vitamin (thiamine), mineral (selenium), electrolyte (magnesium, potassium) deficiencies may occur o Contaminants in alcohol may damage the myocardium

Question 30

What is alcohol’s effects on blood pressure and lipids?

Answer 30

HTN: causal importance in up to 11% of men with HTN o Individuals who drink >2 drinks/day are 1.5 -2x more likely to have HTN than age - and sex - matched nondrinkers o This effect is dose related and most prominent when daily ethanol intake >5 drinks o Abstinence often normalizes systemic arterial pressure • Lipid metabolism: o Ethanol consumption inhibits free fatty oxidation by the liver, which stimulates hepatic triglyceride synthesis and the secretion of low - density lipoprotein o Subjects with hyperlipidemia should be encouraged to limit their ethanol intake

Question 31

What cardiovascular diseases are associated with methamphetamine use? What is thought to be the pathophysiology? What is the major cardiovascular problem associated with methamphetamine use?

Answer 31

CV Disease is the leading cause of death for meth users o HTN o Arrythmia o Aortic dissection o MI o Cardiomyopathy increased from 1.8 to 5.6% of users from 2009-2014 ▪ Also known as MethHF

Question 32

What are cardiovascular complications associated with cocaine use?

Answer 32

``` Angina pectoris • MI • Sudden cardiac death • Cardiomyopathy • HYPERTENSION ```

Question 33

What are the different forms of cocaine?

Answer 33

• Hydrochloride salt: o Alkaloid dissolved in hydrochloric acid to form a water-soluble powder or granule • “Freebase” / CRACK cocaine o Processed with ammonia or sodium bicarbonate (baking soda)

Question 34

What are the modes of administration of cocaine?

Answer 34

``` Cocaine hydrochloride can be taken: o Orally “chewing” o Intravenously “mainlining” o Intranasally “snorting” • Well absorbed through all mucous membranes: o Intranasal o Sublingual o Vaginal o Rectal ```

Question 35

What is the pathophysiology of cocaine use and its’ effects on the cardiovascular system?

Answer 35

Numerous reports of cocaine use with myocardial ischemia and infarction have been documented since 1982 o Mechanisms: ▪ Increased myocardial oxygen demand in the setting of limited/fixed oxygen supply ▪ Marked coronary arterial vasoconstriction ▪ Enhanced platelet aggregation and formation • In vitro studies have shown that cocaine causes structural abnormalities in the endothelial cell barrier: o Increase permeability to LDL o Enhance endothelial adhesion molecule expression: o Favor leukocyte migration

Question 36

What is a patient at significant risk for shortly after use of cocaine?

Answer 36

• In subjects otherwise considered to be at low risk for MI, the risk of infarction increases 24-fold during the 60 minutes after cocaine use