The association of amfetamines and cathinones with acute coronary syndrome – a systematic review

Abstract

Background It is well known that cocaine increases the risk of acute coronary syndrome. However, it is uncertain if the use of other stimulants, such as amfetamines and cathinones, is also related to acute coronary syndrome. Objectives To identify all reported cases of acute coronary syndrome related to the use of amfetamines and cathinones, the type of acute coronary syndrome, the atherothrombotic aetiology, and the mortality rate. Methods A systematic literature search in PubMed, Embase database, Cochrane library, PsycInfo and Web of Science was performed from inception until 31 August 2022. All original articles in English or Dutch describing adult patients with acute coronary syndrome after the use of amfetamines or cathinones were included. The main outcome was the occurrence of acute coronary syndrome associated with amfetamine-type stimulants or cathinones. Data were collected and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results A total of 11,605 articles were identified, 56 of which met the inclusion criteria. A total of 160 patients presented with acute coronary syndrome after five different types of amfetamines, namely, amfetamine (n = 48), metamfetamine (n = 98), 3,4-methylenedioxymetamfetamine (n = 11), fenethylline (n = 2), and 4-fluoroamfetamine (n = 1). Khat chewing was associated with acute coronary syndrome (n = 4234), as were three different types of synthetic cathinones, namely, non-defined cathinones (n = 1), 4-methylmethcathinone (n = 1), and α-pyrrolidinopentiophenone (n = 1). In patients with a known acute coronary syndrome type (n = 157), ST-segment elevation myocardial infarction was diagnosed in 53 patients (75%) and non-ST-segment elevation myocardial infarction in 18 patients (25%). Of the ST-segment elevation myocardial infarction patients, 36% were diagnosed with significant coronary stenosis or thrombus. The mortality rate for khat-associated acute coronary syndrome, with more often male and older patients with fewer cardiovascular risk factors, was higher compared to non-khat-associated acute coronary syndrome. For amfetamine, metamfetamine, and 3,4-methylenedioxymetamfetamine, mortality associated with ST--segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction was 14% and 7%, respectively. Risk factors for acute coronary syndrome were infrequently reported, and risk stratification scores were not reported. Conclusion There is evidence that amfetamine-type stimulants and cathinones are associated with the occurrence of acute coronary syndrome. Khat chewing appears to be a risk factor for acute coronary syndrome. Amfetamine, metamfetamine, 3,4-methylenedioxymetamfetamine, fenethylline, 4-fluoroamfetamine, and synthetic cathinones were also reported in relation to acute coronary syndrome. However, this evidence is limited, of low quality and with a low number of reported cases. Further prospective studies need to be conducted.