P3C271: Myocardial Ischemia: Recognizing a Potentially Reversible Complication of Street Drug Use

Introduction: Illicit drug use is a significant problem among United States youth, with 21.7% of adolescents reporting substance use in 2022. While cocaine and amphetamines are well known for cardiac toxicity, other recreational drugs can also have adverse cardiovascular effects. We present a case of a teen with a history of long-term marijuana (THC) use who experienced myocardial ischemia after ingestion of psilocybin containing mushrooms (PCM) and d-lysergic acid diethylamide (LSD).

Case Description: A 17-year-old non-binary individual (pronouns she/her), with history of gender dysphoria and depression, presented to the emergency department five hours after self-reported ingestion of four “acid gel tablets” (presumed LSD) and one psychedelic mushroom. The patient has a history of daily illicit drug use including THC and hallucinogens. On the day of admission, she vomited multiple times and became acutely agitated; swinging from the light fixture and attempting to climb out the window. EMS evaluation revealed a disoriented teen who was responsive to external stimuli but unable to answer questions coherently. In the emergency department she was afebrile, heart rate 143, and blood pressure 150/78mmHg. Pupils were dilated, lungs clear, and cardiac exam with tachycardia but otherwise normal. Labs included potassium of 3.1 mmol/L but otherwise normal comprehensive metabolic panel, normal creatine kinase, elevated lactic acid of 3.1 mg/dL and leukocytosis. Urine toxicology screen was positive for cannabinoids. EKG showed diffuse ST depression primarily in the inferior lateral leads with ST elevation in lead aVR, V1 and V2 leading to concern for coronary insufficiency. Troponin I was elevated to 0.099 ng/mL (0-0.04 ng/mL) confirming myocardial ischemia. Echocardiogram was normal. Throughout the evaluation the patient denied chest pain and had no change in her respiratory status. She was placed on oxygen and given sublingual nitroglycerin, repeat troponin showed only a mild increase. Daily aspirin was initiated. Over the following 48 hours our patient was monitored on telemetry. She had improvement in her EKG tracings with resolution of ST depression and elevation and normalization of her troponin level.

Discussion: Cardiovascular complications of hallucinogens including LSD and PCM (“magic mushrooms”) typically correspond to general sympathetic arousal and include hypertension and tachycardia. Alteration of serotonin induced platelet function and sympathetically induced arterial vasospasm may contribute to more serious reported complications including tachyarrhythmias and myocardial ischemia or infarction as in our patient. Although widely viewed as safe, THC has been linked to various cardiovascular adverse events including myocardial infarction, arrhythmias, and cardiomyopathy. THC mainly exerts its effects via the sympathetic and parasympathetic nervous system and studies have shown that marijuana plays a role in thrombosis, inflammation, and atherosclerosis.

Conclusion: Cardiovascular complications should be considered when evaluating teens with illicit drug ingestion. This case highlights the cardiac risk with street drug use, particularly hallucinogens and THC.