Dr. Amit Goyal (CardioNerds co-founder), Dr. Jessie Holtzman (House Faculty in CardioNerds Academy and cardiology fellow at UCSF), and Dr. Megan McLaughlin (CardioNerds Scholar and cardiology fellow at UCSF) discuss stimulant-associated cardiomyopathy with Dr. Jonathan Davis (Associate Professor at UCSF the Director of the Heart Failure Program at Zuckerberg San Francisco General Hospital) and Dr. Soraya Azari (Associate Clinical professor at UCSF, with specialty in hospital medicine, primary care, HIV medicine, and addiction medicine).  

Methamphetamine-associated heart failure admissions have steadily increased in the United States over the past decade. Substance use disorders more broadly are thought to complicate at least 15% of all heart failure hospitalizations and amphetamine use has been shown to be an independent predictor of heart failure readmission across the country. At safety net and public hospitals, these numbers may rise even higher. This episode reviews the pathophysiology of stimulant associated cardiomyopathy, highlights treatment options for stimulant use disorder, and discusses novel models of co-management of heart failure and substance use disorder. 

Notes were drafted by Dr. Jessie Holtzman. Audio editing by CardioNerds academy intern, Pace Wetstein.

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1. Though there are no pathognomonic traits of stimulant-associated cardiomyopathy, common echocardiographic features include biventricular dilated cardiomyopathy and/or pulmonary hypertension with a dilated, hypokinetic right ventricle and underfilled left ventricle. Enjoy CardioNerds Episode 312. Case Report: Life in the Fast Lane Leads to a Cardiac Conundrum to learn from a case of stimulant associated pulmonary arterial hypertension.  
   

2. Not all cardiomyopathy in patients who use stimulants is due to stimulant use. Do your due diligence. Patients who use stimulants should undergo a broad work-up to diagnose the etiology of cardiomyopathy.  
   

3. Tips for taking a substance use history: 
   

• Ask permission to discuss the topic. 
  
• Normalize the behavior. 
  
• Use specific drug names (also, learn the local drug nicknames!). 
  
• Ask about any history of prior treatment and periods of abstinence. 
  
• Screen for risk of harm or overdose  
  
• Try using a phrase like “I’m asking you this because I want to know if the way you are using drugs can impact your health and keep you safe.” 
  

4. There are no FDA-approved medications to treat stimulant use disorder. Common off-label therapies include mirtazapine and bupropion/naltrexone.  
   

5. Contingency management programs work off the principle of operant conditioning; they reward patients for maintaining abstinence from substance use.  
   

6. For clinicians to seek assistance in providing treatment for stimulant use disorder, important resources include:  
   

• SAMSA (national help line 1-800-662-HELP or online resource locator) 
  
• HarmReduction.Org 
  
• Never Use Alone hotline (800-484-3731) 
  

1. What are common clinical presentations of stimulant-associated cardiomyopathy?  

• Stimulants have multifactorial physiologic impacts, due both to pharmacologic properties (adrenergic stimulation and vasoconstriction) and direct toxic effects. Clinical manifestations may include hypertension, tachyarrhythmias, acute myocardial infarction, cardiomyopathy, pulmonary hypertension, aortic dissection, and sudden cardiac death.  
  
• On echocardiogram, stimulant-associated cardiomyopathy may manifest as biventricular dilated cardiomyopathy, compensatory tachycardia, LV thrombus, and/or pulmonary hypertension (WHO Group I) 
  

2. What is the pathophysiology of stimulant associated cardiomyopathy?  

• Though the exact mechanisms driving stimulant-associated cardiomyopathy are unknown, myocardial injury is thought to be related to excess catecholamines and the generation of reactive oxygen species, mitochondrial dysfunction, and the downstream effects of microvascular dysfunction and vasospasm.  
  
• Some authors have proposed a two-hit phenomenon whereby stimulant use and vulnerable genetics result in more severe clinical presentations. 
  

3. What are common treatment options for stimulant-associated cardiomyopathy and stimulant use disorder in the presence of cardiovascular disease?  

• As with heart failure in general, start by ensuring that patients receive appropriate goal-directed medical therapy (GDMT) with an ACEI/ARB/ARNI, beta-blocker, MRA, and SGLTi.  
  
• If patients struggle with medication adherence, be sure to address the social determinants of health to allow for improved adherence. For instance, consider using bubble packs to help mitigate polypharmacy.  
  

4. What is the Heart Plus Clinic and how can cardiologists work in an interdisciplinary fashion to address both cardiovascular disease and substance use disorders? 

• The Heart Plus clinic is a multidisciplinary team that links addiction medicine providers and the cardiovascular teams together. The clinic uses contingency management to incentivize abstinence from substance use and works to address barriers to getting medications, taking medications, and navigating polypharmacy. Results are promising so far, with a pilot study demonstrating less stimulant use, more GDMT use, less urgent care use, and more primary care use, along with greater engagement, continuity, and rapport.   
  

5. How do you take a substance use history?   

• Ask permission: “Is it ok if I ask you about ***”  
  
• Normalize the behavior: “Substance use is common” or “I have a lot of patients struggling with ***”  
  
• Use specific names when obtaining a drug use history (not just alcohol, tobacco, “drugs”). Learn the names of drugs in your region.  
  
• Try using phrases like “I’m asking you this because I want to know if the way you are using drugs can impact your health and keep you safe.”   
  
• Ask about their history of past treatment and periods of abstinence. 
  

• Screen for patients at risk of harm and/or overdose due to patterns of use and be sure to prescribe naloxone. 
  

6. What are some useful resources for treating patients with active substance use disorders? 

• Though there currently no FDA-approved medications to treat stimulant use disorder, common off-label therapies include mirtazapine and bupropion/naltrexone. 
  
• Contingency management programs work off the principle of operant conditioning and reward patients for maintaining abstinence from substance use. In contingency management programs, a behavior is chosen that you want to see more frequently, and a reward is given. The reward must be given close to the time of behavior and be of sufficient magnitude to demonstrate the desired effect.   
  

• There are many resources to help both clinicians and patients treat substance sue disorders. Resources include the SAMSA national help line (1-800-662-HELP) or online resource locator for clinicians. Patients may also access HarmReduction.Org and the NeverUseAlone hotline (800-484-3731) for harm reduction resources. 
  

1. DesJardin J, Leyde S, Davis J. Weathering the perfect storm: management of heart failure in patients with substance use disorders. Heart. 2021;107(16):1353-4. doi: 10.1136/heartjnl-2021-319103.

2. Kevil CG, Goeders NE, Woolard MD, Bhuiyan MS, Dominic P, Kolluru GK, et al. Methamphetamine Use and Cardiovascular Disease. Arterioscler Thromb Vasc Biol. 2019;39(9):1739-46. doi: 10.1161/ATVBAHA.119.312461.

3. Kolaitis NA, Saggar R, De Marco T. Methamphetamine-associated pulmonary arterial hypertension. Curr Opin Pulm Med. 2022;28(5):352-60.

4. Leyde S, Abbs E, Suen LW, Martin M, Mitchell A, Davis J, et al. A Mixed-methods Evaluation of an Addiction/Cardiology Pilot Clinic With Contingency Management for Patients With Stimulant-associated Cardiomyopathy. J Addict Med. 2023;17(3):312-8. doi: 10.1097/ADM.0000000000001110.

5. Manja V, Nrusimha A, Gao Y, Sheikh A, McGovern M, Heidenreich PA, et al. Methamphetamine-associated heart failure: a systematic review of observational studies. Heart. 2023;109(3):168-77. doi: 10.1136/heartjnl-2022-321610.

6. Reddy PKV, Ng TMH, Oh EE, Moady G, Elkayam U. Clinical Characteristics and Management of Methamphetamine-Associated Cardiomyopathy: State-of-the-Art Review. J Am Heart Assoc. 2020;9(11):e016704. doi: 10.1161/JAHA.120.016704. https://www.ahajournals.org/doi/epub/10.1161/JAHA.120.016704