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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2023;148:e9–e119. DOI: 10.1161/CIR.0000000000001168 August 29, 2023

Virani et al 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline

Synopsis Various substances can have adverse effects on the cardiovascular system, including cocaine, amphetamines, opioids, alcohol, and marijuana (Table 9). These substances also have the potential for abuse and drug-drug interactions with cardiovascular therapies. Because some of these substances are illicit (eg, cocaine, heroin), studies examining the link between substances and patients with CCD are limited, observational, and with imprecise measures of exposure risk. Although observational data show a J-shaped relationship between alcohol consumption and cardiovascular risk, no RCTs support moderate alcohol consumption to reduce cardiovascular risk.6,11 In fact, recent studies suggest that no safe level of alcohol use is acceptable and that previously observed cardioprotective effects of light-to-moderate alcohol use are likely confounded by other lifestyle and sociodemographic factors.8 With the recent legalization of marijuana and its derivatives in some states, its use in patients with CCD is expected to grow.1 A scientific statement from the AHA highlights the cardiac-specific effects of cannabis, including stimulation of the sympathetic nervous system, platelet activation, endothelial dysfunction, and carbon monoxide toxicity from smoking and inhalation.12 Observational studies of the association between marijuana and cardiovascular events are limited by selection bias with rigorous data about the longterm effect of marijuana and cardiovascular risk lacking.12,13 The AHA released a scientific statement discussing the importance of distinguishing and managing out-of-hospital cardiac arrests from opioids and in engaging patients with opioid use disorders in secondary prevention programs.14 Because of potential cardiac toxicity, drug-drug interactions, and high risk for misuse, long-term opioid use for patients with CCD and chronic pain should be avoided. For recommendations regarding tobacco products, please see Section 4.2.3.

Recommendation-Specific Supportive Text

1 Substance use is underrecognized and can be a

significant contributor to CVD risk and outcomes.1,3,5 Alcohol and other substances, such as cocaine, amphetamines, opioids, and marijuana can have particular adverse cardiovascular effects among patients with CCD (Table 9) and lead to premature or recurrent CVD events. A study across 2 large tertiary care centers found that drug use was observed in 10% of patients <50 years of age presenting with an MI from 2000 to 2016.2 Similarly, recreational substance use of alcohol, cannabis, and amphetamines was independently associated with premature CVD in the nationwide Veterans Affairs Healthcare database and the VITAL (Veterans with Premature Atherosclerosis) registry.15 Single-question screening for unhealthy alcohol and drug use has been validated in primary care settings.4 These simple screening questions can also be self-administered. 2.	 There is a J-shaped relationship between alcohol consumption and death, although data on alcohol consumption is of variable quality. Proposed mechanisms supporting beneficial effects of moderate alcohol consumption include favorable effects on lipids, platelet aggregation, insulin resistance, and endothelial function.16 In the United States, 1 “standard” drink contains about 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).17 Observational studies have consistently found an inverse association between light-to-moderate alcohol consumption and vascular risk.18 In patients with CVD, a similar observation has been documented with light-to-moderate alcohol consumption (5–25 g/d) associated with lower incidence of cardiovascular and all-cause death.6,8,7 Conversely, heavy, episodic drinking (binge drinking) is consistently associated with higher cardiovascular risk including acute myocardial infarction. 3.	 All available data on the benefit of alcohol on

cardiovascular risk are observational and subject to confounding. In the absence of a randomized

Table 9.  Substances With Abuse Potential and Adverse Cardiovascular Effects for Patients With CCD* Substance Potential Adverse Cardiovascular Effects Alcohol J-shaped relationship between alcohol intake and cardiovascular risk in observational studies but limited by confounding.18

Heavy alcohol use and binge drinking associated with increased morbidity and mortality rates.9,10,19 May increase serum triglycerides. Potential drug-drug interactions with cardiovascular therapies.

Cocaine, methamphetamine Stimulation of the sympathetic nervous system.5,20

Platelet activation and aggregation.20 Increased myocardial oxygen demand.5 Can present with cocaine-associated chest pain. MI risk independent of route of administration.21

Opioids Possible association with risk of MI in chronic use.22

High potential for dependence and abuse with chronic use. Potential for drug-drug interactions with cardiovascular therapies.

Marijuana Stimulation of the sympathetic nervous system.

Platelet activation. Endothelial dysfunction. Carbon monoxide toxicity from smoking and inhalatation.12 Route of administration may impact toxicity, with edible products associated with fewer acute cardiovascular symptoms.23

*List is not all inclusive. CCD indicates chronic coronary disease; and MI, myocardial infarction.

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