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Cannabis smoking and sildenafil citrate induced acute coronary syndrome in a patient with myocardial bridge/Miyokart koprusu olan bir hastada esrar icilmesi ve sildenafil sitrat ile induklenen akut koroner sendrom.


Cannabis is a common substance of drug abuse among young adults because of its euphoric and addictive effects (1, 2). The pathophysiological effects of cannabis smoking and its relation to adverse cardiovascular events have been previously reported (1, 2). Sildenafil citrate is widely used as a primary pharmacological treatment of erectile dysfunction in men with and without underlying cardiovascular disease (3). However, the relative contribution of cannabis smoking when combined with sildenafil citrate in pathogenesis of acute coronary syndrome (ACS) is not well known.

We present here a case of cannabis smoking and sildenafil citrate induced ACS in a patient with myocardial bridge.

Case Report

A 42-year-old man presented to the emergency department with severe ongoing chest pain radiating to both arms followed by nausea and excessive sweating. The pain had started shortly after he had smoked two cannabis cigarettes with taking 50 mg sildenafil citrate and had engaged in sexual activity. Patient's history was normal except for smoking. Upon his visit to the emergency, the patient's blood pressure was 110/60 mmHg, with a rapid pulse of 130 beats/min. Initial electrocardiogram (ECG) showed sinus tachycardia and ST segment elevation in leads V1-V3 (Fig. 1A). Because the findings were thought to favor the ACS, the patient immediately underwent a coronary angiography. The left coronary angiogram revealed a myocardial bridging causing 100% systolic compression of mid-segment of left anterior descending artery with return to a normal caliber during diastole (Fig. 2) and right coronary angiogram showed hypoplastic coronary artery. Initial laboratory study revealed mildly elevated creatine kinase MB fraction with 7.1 ng/mL (normal range <5 ng/mL). The patient was started on aspirin, diltiazem, nitrate and lipid lowering agent and discharged home 4 days with disappearance of chest pain and ST elevation on ECG (Fig. 1B) after his cardiac catheterization. He remained asymptomatic and will be followed up regularly to determine whether abstinence from cannabis will prevent him from experiencing any future episodes of ACS.


Cannabis derived from the plant Cannabis sativa is a common drug of abuse among young adults because of its euphoric and addictive effects (1, 2). The effects of cannabis are primarily mediated by the activation of cannabinoid receptors, which are present in brain, heart, blood vessels, spleen and immune system (1,2). Cannabis increases sympathetic activity while decreasing parasympathetic activity, producing tachycardia and increased myocardial contractility (4-6). Additionally, smoked cannabis is associated with an increase in carboxyhemoglobin, resulting in decreased oxygen-carrying capacity (4-6). Therefore, cannabis associated ACS may result from increased oxygen demand not met by a myocardial supply of oxygen (4-6). These adverse hemodynamic changes due to cannabis smoking may lead to plaque rupture in vulnerable individuals culminating in the ACS and sudden death (4-6). The ACS has also been reported in the presence of normal coronary arteries suggesting coronary vasospasm (4-6). Sildenafil citrate alone can cause mean peak reductions in systolic/diastolic blood pressure that are not dose related, whereas the heart rate is unchanged (3). Therefore, these adverse hemodynamic changes, particularly in association with aggravating factors such as decreased blood pressure due to sildenafil citrate may explain the occurrence of symptoms and myocardial ischemia in myocardial bridge.


Our case may suggest that coronary spasm in association with decreased blood pressure due to sildenafil citrate and myocardial bridge was the cause of the ACS in the absence of predisposing causes for thrombosis.


Authors want to thank Woo Jung Chun, MD, Ju Hyeon Oh, MD. for their help


(1.) Ashton CH. Pharmacology and effects of cannabis: a brief review. Br J Psychiatry 2001; 178: 101-6. [CrossRef]

(2.) Caldicott DG, Holmes J, Roberts-Thomson KC, Mahar L. Keep off the grass: marijuana use and acute cardiovascular events. Eur J Emerg Med 2005; 12: 236-44. [CrossRef]

(3.) Jackson G, Montorsi P Cheitlin MD. Cardiovascular safety of sildenafil citrate (Viagra): an updated perspective. Urology 2006; 68: 47-60. [CrossRef]

(4.) Bachs L, Morland H. Acute cardiovascular fatalities following cannabis use. Forensic Sci Int 2001; 124: 200-3. [CrossRef]

(5.) Fisher BA, Ghuran A, Vadamalai V, Antonios TF. Cardiovascular complications induced by cannabis smoking: a case report and review of the literature. Emerg Med J 2005; 22: 679-80. [CrossRef]

(6.) Lindsay AC, Foale RA, Warren 0, Henry JA. Cannabis as a precipitant of cardiovascular emergencies. Int J Cardiol 2005; 104: 230-2. [CrossRef]

Kyung Been Lee, Bong Gun Song, Gu Hyun Kang, Yong Hwan Park

Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon-Korea

Address for Correspondence/Yazisma Adresi: Dr. Bong Gun Song Division of Cardiology, Cardiac and Vascular Center Department of Medicine, Samsung Changwon Hospital Sungkyunkwan University School of Medicine #50, Changwon, 630-723-Korea

Phone: 82-55-602-6327 Fax: 82-55-290-6654


Available Online Date/Cevrimici Yayin Tarihi: 17.12.2012

doi: 10.5152/akd.2013.045
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Article Details
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Title Annotation:Case Reports/Olgu Sunumlari
Author:Lee, Kyung Been; Song, Bong Gun; Kang, Gu Hyun; Park, Yong Hwan
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Date:Mar 1, 2013
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