313. Stimulant-Associated Cardiomyopathy with Dr. Soraya Azari and Dr. Jonathan Davis

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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Pearls - Stimulant-Associated Cardiomyopathy




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.  





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.  





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.” 





There are 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; they reward patients for maintaining abstinence from substance use.  





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) 




Show notes - Stimulant-Associated Cardiomyopathy



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,