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• People with cardiovascular disease who took an erectile dysfunction (ED) drug and a medication for angina, or chest pain, had a higher risk of early death.
• The ED drugs examined in the study are phosphodiesterase type 5 inhibitors (PDE5i), sold under the brand names Viagra, Levitra, Cialis and others.
• People taking both of these types of medications should talk to their doctor about stopping one or both of the medications, or possible alternative treatments.

A new study finds that Viagra, Cialis, and other similar types of medication are linked to a higher risk of cardiac issues for people who also take medication for chest pain.

Phosphodiesterase type 5 inhibitors (PDE5i) — sold under the brand names Viagra, Levitra, Cialis and others — are a common treatment for erectile dysfunction (ED) in people with cardiovascular disease.

However, people prescribed both a PDE5i for ED and a nitrate for angina (chest pain) had a higher risk of heart failure, early death, and other negative health outcomes, a new study shows.

“Physicians are seeing an increase of requests for erectile dysfunction drugs from men with cardiovascular diseases,” said senior study author Dr. Daniel P. Andersson, associate professor at Karolinska Institutet in Stockholm, Sweden, in a news release.

“While there is a positive association of ED medication for men with cardiovascular disease, patients taking nitrates may experience an increased risk of negative health outcomes,” he said.

The study was published Jan. 15 in the Journal of the American College of Cardiology.

Why using both Viagra and nitrates are not recommended

The use of PDE5i treatment in people with cardiovascular disease and ED has been controversial, the authors of the new paper write. These drugs can affect blood flow, disrupt the lining of the blood vessels, and cause oxidative stress.

In addition, use of a PDE5i and nitrate together is not recommended, because both types of drugs can cause drops in blood pressure, but through different mechanisms. In spite of this, some research has found that the number of people prescribed both types of drugs is growing.

In the new study, researchers examined whether men with cardiovascular disease who were prescribed both drugs had a higher risk of certain cardiovascular outcomes.

The study included 61,487 men who had a history of a myocardial infarction (heart attack) or percutaneous intervention (treatment to open a blocked artery, also known as revascularization) from 2005 to 2013. The data came from the Swedish Patient Registry.

In addition, participants filled at least two prescriptions for nitrates — sublingual nitroglycerin or oral nitrates — during that time. Some participants also filled at least two prescriptions for a PDE5i —sildenafil, vardenafil, tadalafil or a combination of those.

Among these men, 55,777 were treated with nitrates alone, and 5,710 were treated with nitrates and a PDE5i. Researchers followed nitrate-only users for an average of 5.7 years, and PDE5i and nitrate users for an average of 3.4 years.

The average age of the nitrate-only users was 70 years, and the average age of men treated with a PDE5i and nitrate was 61 years.

Researchers examined medical data to see how many men died early from any cause, or from a cardiovascular or other cause; or had a heart attack, heart failure, or any major cardiovascular event; or needed cardiac revascularization.

People taking both a PDE5i and nitrate had a higher risk of all of those health outcomes, compared to those taking a nitrate alone, the study showed.

However, few of these negative health events occurred 28 days after participants filled the prescription for a PDE5i, “indicating a low immediate risk for any event,” the researchers wrote.

Dr. Cheng-Han Chen, interventional cardiologist and medical director of the Structural Heart Program at MemorialCare Saddleback Medical Center in Laguna Hills, Calif., wasn’t surprised by the study’s findings.

Chen was not involved in the study.

“We have known for a long time that using a PDE5i along with nitrates can result in an unsafe drop in blood pressure,” he told Healthline. “This study clearly confirms that this combination can result in increased risk of cardiovascular events and even mortality.”

What to know about heart health and erectile dysfunction

One of the limitations of the study is that researchers did not know if patients took the medications that they were prescribed, or how often — only that they filled the prescription.

The study also included people who had already had a heart attack or underwent revascularization, which makes them high-risk. As a result, the findings may not apply to other groups of people.

In addition, the study is observational, so it cannot show direct cause and effect. 

It could be that the increased risk of negative health outcomes is due to both types of medications causing dilation of the blood vessels, said Dr. Yu-Ming Ni, cardiologist and lipidologist at MemorialCare Heart and Vascular Institute at Orange Coast Medical Center in Fountain Valley, Calif. 

However, there could be other reasons for the increased rates of early death in people taking both drugs, he told Healthline. For example, the need for a PDE5i may be a sign of more severe cardiovascular disease overall.

“Having erectile dysfunction can be related to poor blood flow in the penis,” said Ni. However, “we know that having blood vessel disease in arteries in one part of the body suggests you’re going to have blood vessel disease in arteries in other parts of the body.”

More research is needed to understand the link between the use of these drugs and the negative health outcomes seen in this study.

In general, people should not be on both medications at the same time, Ni said, something backed up by the new study’s findings.

However, “many men [taking a nitrate] also happen to be on erectile dysfunction medications at the same time, and [your physician] may not be aware of it, for various reasons,” he said. “So it’s really important to bring this to the attention of your physician, if you’re taking both.”

Chen recommends that if you are taking both types of medications, you should talk to your primary care provider or cardiologist about stopping one or both drugs.

In addition, “patients with both ED and angina should know that there are alternatives to nitrates — such as calcium-channel blockers and ranolazine — that can be more safely used if they are taking a PDE5i,” he said.

Takeaway

Researchers examined medical data on men with cardiovascular disease who were prescribed a nitrate for angina, or chest pain. Some were also prescribed a phosphodiesterase type 5 inhibitors (PDE5i) for erectile dysfunction.

Men who were prescribed both types of drugs had a higher risk of dying early, heart attack, and other cardiovascular outcomes, compared to those who were prescribed only a nitrate.

Experts say that, in general, these two types of medications should not be used together. If you are taking both drugs, talk to your doctor about stopping one or both meds, or finding an alternative medication.

• Pharmaceutical company Eli Lilly is urging people not to use its tirzepatide medications Mounjaro and Zepbound for cosmetic weight loss.
• They said the drugs are designed for serious diseases and can pose potentially serious health risks to people using them for other purposes.
• Experts say the benefits of these drugs outweigh the risks for people with obesity, but that balance may not be true for someone trying to lose a minimal amount of weight.

Officials at Eli Lilly have posted an open letter regarding the use of its FDA-approved tirzepatide medications, Mounjaro and Zepbound, for cosmetic weight loss.

The company stated that it was aware of the practice of these drugs being prescribed or used outside of the parameters of the Food and Drug Administration as well as the use of tirzepatide by compounding pharmacies that mix customized medicines.

“Mounjaro and Zepbound are indicated for the treatment of serious diseases; they are not approved for – and should not be used for – cosmetic weight loss,” the statement reads.

“Products claiming to contain tirzepatide, Mounjaro, or Zepbound that are made and/or distributed by compounding pharmacies have not been reviewed by the FDA or global regulatory agencies for safety, quality, or efficacy; are not FDA-approved or approved by global regulatory agencies like Mounjaro and Zepbound; and may expose patients to potentially serious health risks,” the officials added.

Are Mounjaro and Zepbound safe to take for weight loss?

Mounjaro is available in injectable single-dose pens or vials.

It is recommended for adults with type 2 diabetes to improve blood sugar, but it is meant to be combined with dietary and exercise changes.

There is an FDA warning on Mounjaro about a potential increased risk for thyroid cancer.

Other side effects include:

• Pancreatitis
• Hypoglycemia
• Allergic reactions such as rash or swelling
• Kidney failure
• Diarrhea
• Nausea
• Vomiting
• Vision changes
• Gallbladder pain
• Jaundice
• constipation

Zepbound is also injectable and is meant for adults who are overweight or have obesity.

The company’s recommendation is that it be used with a reduced-calorie diet and an increase in physical activity.

Zepbound also has an FDA warning about potential thyroid cancer risk.

Other side effects include:

• depression
• hair loss
• heartburn
• hypoglycemia
• allergic reactions such as rash or swelling
• pancreatitis
• jaundice

In referring to drugs containing tirzepatide, Dr. Dan Azagury, FACS, the chief bariatric surgeon and medical director of Stanford University School of Medicine’s Lifestyle and Weight Management Clinic in California, said using the medications for cosmetic purposes is not recommendable.

Aside from the side effects, he said the drugs can create longer-term problems for people who are trying to lose weight quickly rather than applying dietary and exercise regimens over time for overall health.

“We tell our patients that if they start the drug they should do so being comfortable with the idea of staying on it forever,” Azagury told Healthline. “Because often when you stop there is a rebound effect. In particular, if you stop abruptly. Patients who take this just to lose 5 to 10 pounds and stop will then likely regain 10 to 15 pounds, leading to worse long-term outcomes and a yo-yo effect that is unfavorable. I think educating patients in that way would be beneficial.”

Are Mounjaro and Zepbound different than Ozempic?

Ozempic, along with drugs such as Wegovy, are commonly called GLP-1 drugs, or glucagon-like peptide1 receptor agonists. Tirzepatide drugs are part of the GLP-1 class.

Ozempic is meant to be prescribed to adults with type 2 diabetes to help lower risks of heart disease and manage blood sugar levels, but it is also prescribed off-label — where a drug that’s approved for certain conditions is prescribed for another purpose — for weight loss or weight management.

Wegovy is recommended with exercise and a low calorie diet for long-term weight loss in:

• adults with a body mass index (BMI) of 30 or higher (obesity)
• adults with a BMI of 27 or higher (which is considered overweight) and a health condition that’s related to weight
• children 12 years and older whose BMI is in the 95th percentile or higher (which is considered obesity)

All GLP-1 drugs have been found to be linked to serious gastrointestinal side effects, some of which can require hospitalization.

Research published in October 2023 reported strong associations with intestinal blockage and pancreatitis in users of GLP-1 drugs.

Risks vs benefits in using tirzepatide drugs

Azagury said that the use of these type of drugs for purposes other than those approved by the FDA can change the risk factors for people.

“Every drug has side effects and potential risks. When the FDA approves a drug, they weight the benefits vs the risks,” Azagury said. “They issue an indication for use based on that equation. If you’re doing it for cosmetic purposes with no health benefit, then that equation is different and the side effects or risks might outweigh the benefits.”

Dr. Mir Ali, a bariatric surgeon and medical director of MemorialCare Surgical Weight Loss Center at Orange Coast Medical Center in California, said the statement by Eli Lilly will likely make no difference on how people look for cosmetic weight loss treatments.

“Patients seeking these medications for weight loss will try to obtain them regardless of any warnings,” Ali told Healthline. “These medicines are in short supply because the demand is so high. Many patients who do not meet the manufacturers’ guidelines are seeking these medications for weight loss. These medicines are more effective than diet and exercise alone, so people who do not have significant weight view them as a more convenient solution.”

That type of demand, Azagury said, is also creating problems or people for whom tirzepatide drugs would be beneficial for long-term health.

“It’s unfortunate because this is an expensive drug that is extremely beneficial to patients with obesity and they have difficulty accessing it,” he said. “Its use for cosmetic by people who can afford it is increasing disparities and reducing access for patients who would truly benefit.”

• A new study shows women with perinatal depression are associated with a greater risk of dying by suicide, particularly during the first year of their diagnosis.
• Many factors affect perinatal depression onset, including hormone changes during and after pregnancy, personal or family history of depression, major life stressors, and marital conflict.
• To treat this type of depression, experts recommend psychotherapy and antidepressants in serious cases.

A new study shows that women with clinically diagnosed perinatal depression face an increased risk of death as a result of suicide, especially during the first year after receiving a diagnosis. The results were published January 10 in the BMJ.

Researchers examined data from the Swedish national registry between 2001 and 2018 and found 86,551 women with a first-time diagnosis of perinatal depression and 865,510 women without perinatal depression who gave birth around the same age and during the same year.

They also looked at data for 24,473 of the women who had perinatal depression with 246,113 full sisters who were unaffected by this illness and gave birth to at least one baby throughout the study duration.

The findings demonstrate that women with perinatal depression are more than twice as likely to die compared to women who do not have perinatal depression. The risk appears highest during the first year after being diagnosed.

While suicide is rare for people with perinatal depression, the increase in suicide was nearly six fold compared to people without this mental illness. Those with perinatal depression were also three times as likely to die from an accident, the researchers report.

“This study uses a large dataset from Swedish registries and demonstrates a significant association between peripartum depression and risk of suicidal behavior,” Dr. Khatiya Moon, a psychiatrist at Northwell Health, told Healthline. Moon was not involved in the research.

“A strength of the study is that the investigators tried to control for factors like upbringing and previous history of depression or other psychiatric disorders, which could otherwise confound the results,” she added.

Perinatal depression linked to increased suicide risk

In the study, researchers discovered that women with perinatal depression had a greater risk of mortality.

The findings were consistent regardless of any pre-existing psychiatric conditions, particularly among people who died by suicide and during the first year after being diagnosed. 

“Becoming a parent is a major life transition,” Moon said. “Not only are there massive hormonal shifts that affect the brain and body of the postpartum person, the psychological transition to parenthood is among the most dramatic changes most people ever go through.” 

“The parenthood transition also changes how a person relates to others and what supports they may need. Without the right support, the postpartum period can be fraught with challenges. This study is another reason to take perinatal depression seriously as a contributor to maternal mortality,” Moon added.

The study also highlights the risks associated with major depression, a recurrent mental illness.

“Major depression is a serious illness associated with high risk for other medical illness and mortality, including suicide,” Dr. Adele Viguera, associate director of the Perinatal and Reproductive Psychiatry Program at Cleveland Clinic, told Healthline. Viguera was not involved in the new research.

“These findings underscore the serious morbidity and elevated mortality associated with major depression, whether postpartum or not. If a person has had one episode of major depression, their risk for developing a subsequent episode is around 50%,” Viguera noted.

“If an individual has experienced at least two episodes, their risk for having another episode increases to 80%. Postpartum depression is no different with respect to these serious consequences, including elevated risk for subsequent recurrences both postpartum and outside of the postpartum period,” Viguera continued.

Michele Goldman, a psychologist with the Hope for Depression Research Foundation, told Healthline while the study highlights the importance of monitoring and intervening in higher-risk populations, “there was a lack of clarity in the study that brings up additional questions about the findings.”

“The study defines depression as people having received a diagnosis by a professional after receiving specialized care or because someone was dispensed an antidepressant medication,” Goldman explained.

“Being on an antidepressant medication does not constitute a diagnosis of depression; further, there are people on antidepressant medications to treat other conditions (not depression). Therefore, their main criteria to categorize women as having depression is not necessarily a sound measure,” Goldman noted.

What causes perinatal depression?

Many factors contribute to perinatal depression, the period before and after the birth of a child.

Moon said the exact causes of perinatal depression are not fully understood but noted the causes may vary from person to person.

“Previous studies looking at this question have suggested that some women with PND may have differences in how their body treats GABA, an important neurotransmitter that is involved in regulating mood,” Moon said.

“This was part of the rationale in the development of zuranolone and brexanolone, which are both FDA approved for [the] treatment of postpartum depression and both involved in GABA modulation,” he added.

The postpartum period also brings a rapid shift in hormones such as estrogen, progesterone, and allopregnanolone. Postpartum depression affects around 1 in 8 pregnancies, according to the Centers for Disease Control and Prevention (CDC).

“As these hormones influence mood-regulating neurotransmitters, it is thought they may play a role in postpartum depression,” Viguera said.

“However, studies find no consistent link between hormone levels and mood issues after birth. Still, some think certain women are extra sensitive to postpartum hormonal shifts, making them vulnerable to postpartum depression and related mood problems during menstruation and menopause,” she added.

Beyond hormones, other factors also seem to be at play. 

“Consistently, women who report marital dissatisfaction, insufficient social support, and stressful events during or after pregnancy have higher rates of postpartum depression,” Viguera said.

“The condition likely indicates an underlying susceptibility to depressive disorders. Women with histories of depression or bipolar disorder are at greater risk, and women who develop postpartum depression often have recurring depressive episodes unrelated to reproduction.”

While hormones may contribute to perinatal and postpartum depression onset, psychological and social factors also affect risk a person’s risk.

All new birthing parents are at risk for developing postpartum depression regardless of age, relationship status, education, or income level. However, certain risk factors may increase a person’s likelihood of developing this debilitating mental health condition. According to Viguera, these include:

• previous postpartum depression
• depression during pregnancy
• personal or family history of depression 
• recent major stressors
• inadequate social support system 
• marital conflict

How is perinatal depression treated?

Perinatal and postpartum depression is treatable, especially when diagnosed early.

“It is imperative to evaluate and diagnose postpartum mood disturbances,” Viguera said.

“Often, a first step is screening, followed by referral to an expert in this area. The approach to treatment is multi-prolonged and can include a variety of treatment modalities, usually in combination such as with talk therapy, medications, involving family members to provide support at home and community support services.”

Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are commonly prescribed for treating perinatal and postpartum depression.

“These can help manage symptoms and regulate mood,” said Viguera. 

“An exciting development in the treatment of postpartum depression is the recent release of the first-ever FDA-approved antidepressant indicated for postpartum depression called zuranolone (Zurzuvae), the first rapid-acting oral short-course treatment specifically for moderate to severe [postpartum depression] PPD. Onset of action is seen as early as day 3 in clinical trials,” she noted.

Various psychotherapies can also be very helpful in treating postpartum depression. 

“For example, cognitive behavioral therapy helps identify and change negative thought patterns, or interpersonal therapy focuses on improving communication and relationships,” Viguera said, noting that group therapy connects pregnant and postpartum people around similar difficulties.

In many cases, the combination of talk therapy and medication provides a better outcome for recovery than either modality alone. Other helpful interventions for perinatal depression may include:

• getting adequate sleep
• following a balanced diet
• exercising regularly
• joining support groups

“Having a strong support system is also crucial,” Viguera said. “Partners, family, and friends can provide emotional support and practical help with child care to alleviate stress. In general, treatment is tailored to each woman’s needs and symptoms with the goal of restoring mood and daily functioning.”

Moon added that pre- and post-natal care appointments “go a long way” for most people.

“Pregnancy and parenthood also provide the opportunity to connect with people in one’s community in a new way, and it can be helpful to build networks of other parents through childbirth and parenting classes, support groups, and mother-infant classes,” Moon said.

If you’re experiencing symptoms of peripartum anxiety and depression, it’s important to seek treatment and bring up concerns to your healthcare team, such as an OB-GYN.

Takeaway

A new Swedish study shows an increased risk of death, particularly death by suicide, among people diagnosed with perinatal depression.

The findings highlight the mortality risks associated with perinatal, postpartum, and major depression, which are debilitating mental health disorders when untreated.

“It is well known that people with mental disorders experience excess mortality compared with the general population,” Viguera said. “Postpartum depression is no different with respect to these serious consequences.”

With the emergence at the end of last year of COVID-19 variant JN.1, there are questions about how it compares to the many other variants that have been identified. JN.1 descends from variant BA.2.86 and has an additional mutation in …

• Pharmaceutical company Eli Lilly will begin offering an “end-to-end” healthcare experience called LillyDirect.
• The service will help patients get access to doctors and to the company’s medicines, including weight loss drug Zepbound.
• Obesity doctors welcomed the announcement, saying it will help expand access for many Americans.

American pharmaceutical company Eli Lilly will begin offering a suite of healthcare services, including access to independent telehealth providers and free shipping on medication.

The company announced the launch of LillyDirect on January 4, 2024, and bills it as an “end-to-end digital healthcare experience.” The program is targeted at individuals with obesity, migraine, and diabetes.

It will offer pharmacy and healthcare services, including convenient access to medications like insulin and the recently approved obesity medication Zepbound.

“With LillyDirect, our goal is to relieve some of those burdens by simplifying the patient experience to help improve outcomes. LillyDirect offers more choices in how and where people access healthcare, including a convenient home delivery option to fill Lilly medicines they have been prescribed,” David A. Ricks, Eli Lilly’s chair and CEO said in a press release.

Services offered by LillyDirect include:

• Access to an online pharmacy for the company’s medicines with free shipping.
• Educational information about disease management.
• Tools to find independent healthcare providers via both telehealth and in-person settings.
• Manufacturer savings on medicines

Eli Lilly has partnered with telehealth company Form Health for telehealth options and Healthgrades for in-person doctors. They also make it clear that all healthcare providers are independent of Eli Lilly.

“The LillyDirect listing is not an endorsement or recommendation of the independent clinician networks or telehealth clinicians. The telehealth service providers and healthcare professionals listed through the “find in-person care” feature on LillyDirect are independent and separate from Lilly. Treatment decisions and prescribing practices are made at the discretion of the provider’s care team,” a representative for Eli Lilly told Healthline in an emailed statement.

A welcome addition to obesity care

Dr. Caroline Apovian, MD, a Professor of Medicine at Harvard Medical School and the co-director of the Center for Weight Management and Wellness at Brigham and Women’s Hospital, welcomed the announcement.

“I think this is a great move. Lilly is really helping patients by getting them to a telemedicine program run by doctors who can get them access,” she told Healthline.

Those sentiments were echoed by other experts contacted for this story.

“From my perspective, anything that helps patients have access to care, and in particular to specialized high quality care and drugs is positive,” said Dr. Dan Azagury, MD, section chief of Minimally Invasive and Bariatric Surgery and medical director for the Bariatric and Metabolic Interdisciplinary clinic at Stanford University.

Both Apovian and Azagury disclosed that they are medical consultants to Form Health.

Lowering barriers to access

Telehealth services that sprang to life during the pandemic are now important to obesity care. Both Azagury and Apovian say that telehealth is now essential to help them keep up with the demand for care.

“I would say, in general, obesity care lends itself very well to telehealth. I’ll tell you that my practice has switched to telehealth because of COVID, but we’ve never switched back,” said Azagury.

“There are many people out there who want our services. We are hiring more physician assistants and nurse practitioners to help the MDs and hiring more MDs because clearly with 42% of Americans who need obesity treatment, we don’t have enough obesity medicine specialists to do it,” said Apovian.

Apovian told Healthline that telehealth services also give her greater freedom to see patients who require more complex care and have serious comorbidities.

“My slots in my center to see in-person patients can be reserved for patients with congestive heart failure and obesity or kidney failure with obesity,” she said.

Ongoing obesity drug shortages

LillyDirect could also help play a role in ensuring that patients who need medication can reliably get it.

Novel diabetes and obesity medications known as glucagon-like peptide-1 receptor agonists (GLP-1 RAs), including semaglutide (Ozempic, Wegovy) and tirzepatide (Mounjaro, Zepbound), have proven to be exceptionally effective for weight loss. They have simultaneously grown in popularity and burst into pop culture and headlines across the United States.

However, the popularity of the drugs has been a blessing and a curse. Novo Nordisk, the Danish pharmaceutical company behind Ozempic and Wegovy has faced numerous shortages and supply chain issues while attempting to keep up with demand.

The conundrum has, in some instances, left patients unable to get access to their medication. 

Just this week, Ricks said that Zepbound had reached 25,000 new prescriptions per week and that the company’s current output might not meet demand. While the company is investing in more manufacturing infrastructure, how much of the drug they can actually produce is unclear.

The bottom line

American pharmaceutical company Eli Lilly will begin offering healthcare services through their new program LillyDirect.

LillyDirect services include an online pharmacy, tools for finding in-person and telehealth doctors, and some financial incentives like free shipping and manufacturer savings on medication.

Obesity experts contacted by Healthline were supportive of the initiative, saying that it would help expand access and help meet surging demand for obesity drugs, including Zepbound.

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• New research indicates that chronic pain patients using medical cannabis are at a higher risk of heart arrhythmia than non-users.
• The Danish study noted a two-fold increase in the risk of arrhythmia, although the overall risk was still low.
• More research is needed to establish a link between cannabis and cardiovascular disease.

People who use medical cannabis for chronic pain are more likely to experience atrial fibrillation and other forms of heart arrhythmia compared to non-users. 

Those are the findings of a study published this week in the European Heart Journal.

However, the authors noted that data on medical cannabis is still lacking due to legality issues, and more research is needed to support the findings.

Additionally, the authors also noted that the study did not address whether the risk is linked specifically to smoking cannabis, ingesting cannabis edibles, or a combination of both.

Another major limitation that the authors noted is that the study was not able to look at “disease severity, clinical measures, blood tests, and lifestyle factors,” all of which could contribute to an increased risk of heart issues independent of cannabis use.

Although the risk of arrhythmia among medical cannabis users was still low, it was statistically significant.

Researchers did not find any association between medical cannabis and acute coronary disease (ACS), an umbrella term that includes serious cardiovascular events like heart attack and unstable angina.

“There is very insufficient evidence related to medical cannabis and cardiovascular side-effects. Clinically, associations have previously been found with recreational cannabis use, but to our knowledge, this is the first study investigating associations with prescribed medical cannabis,” Dr. Anders Holt, MD, of Copenhagen University in Denmark, and author of the study told Healthline.

A Two-fold increase in arrhythmia risk

The study found that risk of new-onset arrhythmia, which included conditions like atrial fibrillation, flutter, and paroxysmal tachycardia, was doubled in those who used medical cannabis to manage chronic pain compared to a control group.

Holt and his team utilized health data from national Danish health registries to investigate the link between medical cannabis and arrhythmia. Medical cannabis is not formally approved for chronic pain management in Denmark, but a government program has allowed physicians to prescribe it for that reason.

Researchers looked at data from more than 1.8 million patients with chronic pain.

Out of that group, only a very small number of patients received medical cannabis: about 5,000 people.

The group of medical cannabis users were matched 1:5 with 27,000 patients that had similar characteristics, including age, sex, and use of other pain medications.

In large, population-based studies like this, it is impossible to remove all confounding factors, but the goal is to remove as many as possible. 

Patients in the study did not have a history of arrhythmia, nor had they previously been prescribed medical cannabis.

Over a 180-day follow-up period, 42 patients who used medical cannabis developed an arrhythmia; in three out of four cases, it was atrial fibrillation.

Overall 0.8% of medical cannabis patients experienced an arrhythmia compared to 0.4% in the control group. The risk was greatest in patients with cancer and cardiometabolic conditions like diabetes. 

No association was found between medical cannabis and acute coronary syndrome.

“These findings should spur further investigations into the viable use of cannabis treatment for chronic pain and particularly into possible side effects. It should be paramount to physicians that the ongoing legalization of cannabis meant for therapeutic use is kept purely scientific and not political,” said Holt.

Statistical versus clinical risk

Although the study demonstrates an increase in risk, questions remain about how this risk should factor into patient care.

“You need to distinguish statistical significance from clinical significance,” said Dr. Rod Passman, MD, a Professor of Medicine and Director of the Center for Arrhythmia Research at Northwestern University. Passman wasn’t affiliated with the study.

“If you tell someone their risk is double, that’s really important. But if you tell someone their risk goes from 0.4% to 0.8%, most of us would not believe that that is a major increase in risk that would impact clinical decision making like whether I would take a medication or not,” he said.

He notes that many pain medications, even over-the-counter nonsteroidal (NSAID) medications like ibuprofen, are associated with arrhythmia.

Opioids, pervasive and powerful pain medicines like morphine, codeine, and fentanyl, are too.

A 2018 review found that even at low doses could increase the risk of arrhythmia.

Patients and healthcare professionals will always need to assess risks and benefits when assessing treatment needs.

“I don’t think that I would take someone who was in chronic pain, which failed typical therapies, and prevent them from getting medical marijuana because of the potential risk of exacerbating their atrial fibrillation when that risk is going to be relatively low,” he said.

A dearth of data on medical cannabis

Both Passman and Holt acknowledge that good data on medical cannabis is sorely lacking. Prior research has tended to focus on recreational cannabis usage. With the rise of legalization in Europe and the United States, use of medical cannabis is steadily increasing. 

“This is of increasing interest given the increasing use of cannabis, both for medical and recreational purposes…Often there’s a lot of problems with these studies because, historically, this has been an illegal medication. So we don’t have a lot of good, solid data on it,” said Passman.

“Prescribed medical treatment must be founded on sufficient evidence of effect, including considerable knowledge on side-effects which this study adds a sliver of, but more is certainly needed,” said Holt. 

The American Heart Association has stated that there are “no cardiovascular benefits” to using cannabis, either recreationally or medicinally. In a scientific statement on cannabis and cardiovascular health issued in 2020, the AHA points out that in a variety of studies, cannabis consumption has been associated with atrial fibrillation and cardiovascular disease. They too, acknowledge a need for more and higher quality data and that there is “an urgent need for carefully designed, prospective short- and long-term studies.”

AHA spokesperson Robert L. Page II, PharmD, a Professor at the University of Colorado and Chair of the AHA’s 2020 scientific statement on cannabis, told Healthline that the Danish research “absolutely” aligns with the AHA’s statement.

“I treat cannabis use (particularly when vaped or smoked) as a potential risk factor for heart disease, which is why I do not recommend smoking or vaping any form of cannabis. Thus, medical providers should be screening for underlying cardiovascular risk factors or underlying conditions that could contribute to a heart attack, stroke or heart rhythm disturbance in anyone who uses cannabis,” he said.

The Bottom Line

A European study found that patients with chronic pain who used medical cannabis were more likely to experience heart arrhythmia than a control group.

While the risk of arrhythmia was still low (0.8%) among the medical cannabis group, it was a two-fold increase over the control group (0.4%).

Researchers and organizations, including the American Heart Association, say there is a tremendous need for more studies and high quality data on the association between cannabis and cardiovascular disease.

• Actor Barry Keoghan has revealed that he developed necrotizing fasciitis — a potentially deadly infection.
• Necrotizing fasciitis is a serious infection that can lead to amputation and death. 
• Symptoms include fever and chills, blisters, ulcers and black spots on the skin, and confusion, shock, and drowsiness. 
• Patients who suspect they have contracted necrotizing fasciitis should seek urgent medical care. 

Actor Barry Keoghan has revealed he almost died from necrotizing fasciitis infection.

The Irish actor, best known for his roles in Saltburn and The Banshees Of Inisherin, told GQ that he developed the life threatening infection in his arm in October 2022.

In the interview, Keoghan recalls asking doctors, “But I’m not gonna die, right?” and the doctors responding, “Well, we don’t know.”

“I’m not sure if he was on a lot of meds, but he seemed to shrug it off,” Martin McDonagh, the British-Irish playwright who wrote Keoghan’s role in The Banshees Of Inisherin, told GQ. “We were only about four days out from shooting, and his arm was puffed up. But he was like, ‘Yeah, no, I’m going to be fine — I’ll see you on Tuesday.’”

Though rare, necrotizing fasciitis infection can spread quickly through the body and become deadly.

What is necrotizing fasciitis infection?

“Necrotizing fasciitis is a rare and life-threatening infection that causes the death of the body’s soft tissue,” explains Dr. Semiya Aziz, founder of Say GP.

“It can happen when a wound gets infected by certain types of bacteria, most commonly streptococcal bacteria.”

As the infection spreads, it produces toxins that destroy nearby tissue, harm blood vessels, and stop the flow of blood.

If not treated quickly, it can cause serious side effects like septic shock and organ failure, sometimes resulting in the need for amputation.

Highlighting the seriousness of the infection, Aziz says even with treatment, the infection can be fatal in up to 30% of cases.

How does a necrotizing fasciitis infection develop?

“Bacteria can enter through a break in the skin like a cut or burn,” says Dr. Christina M Wojewoda, chair of the College of American Pathologists Microbiology Committee. “Those bacteria have toxins and other pathogenic factors that can lead to the death of tissue.”

It’s important to note that there are different types of necrotizing fasciitis due to the strain of bacteria that causes the infection.

Wojewoda says the most common type of necrotizing fasciitis is caused by a mixture of different types of bacteria and usually occurs in the abdominal or groin areas.

The next most common type is due to Streptococcus pyogenes, the same bacterium that causes strep throat. “This is more common in young, healthy adults with a history of injury and involves the extremities,” Wojewoda explains. “The third type is Vibrio vulnificus, which is found in seawater.”

While anyone can contract necrotizing fasciitis, Aziz points out that some people will be more at risk of developing it, such as those living with diabetes, have a weakened immune system, or living with a chronic illness.

Symptoms of necrotizing fasciitis infection

Symptoms of necrotizing fasciitis can include:

• Fever and chills
• Nausea and vomiting
• Diarrhea
• Blisters, ulcers, and black spots on the skin
• Intense pain or loss of feeling near the cut or wound
• Confusion and drowsiness
• Shock
• Swelling

Recognizing the symptoms of necrotizing fasciitis infection is crucial. Aziz says the symptoms can vary depending on the stage and severity of the infection.

However, people most commonly experience fever, chills, nausea, vomiting, and diarrhea.

“These are signs of systemic infection or sepsis,” Aziz explains.

The infection also causes blisters, ulcers, or black spots on the skin, which may indicate tissue death or gangrene.

“There may be intense pain or loss of feeling near a cut or wound, and the pain may be much worse than expected from the injury,” Aziz adds.

You should also look out for confusion, drowsiness, or shock — which are signs of low blood pressure or organ failure — as well as swelling, redness, and warmth of the skin around the affected area.

What to do if you suspect you have necrotizing fasciitis

Delays in treatment can lead to death, so Aziz says it’s crucial that you seek medical care right away.

To get medical help, you should either call 911 or go to the nearest emergency room as soon as possible.

When you seek medical assistance, Aziz says you can expect to be examined by a doctor who will look for signs of necrotizing fasciitis, such as severe pain, swelling, redness, blisters, and skin discoloration.

They may also run blood and imaging tests and take tissue samples to confirm the diagnosis and identify the type of bacteria causing the infection.

Once diagnosed, necrotizing fasciitis is typically treated with a combination of antibiotics, surgery, and supportive care.

In some cases, Aziz says amputation of the affected limb may be necessary to save the patient’s life.

How to reduce your risk of necrotizing fasciitis

As with many diseases and infections, prevention is better than cure. So, what can you do to minimize your risk of contracting necrotizing fasciitis?

Remember, bacteria can be introduced through cuts, burns, insect bites, surgery, or injecting drugs.

“If you have a break in the skin, make sure to keep it clean with soap and water and cover it with a clean bandage until healed,” advises Wojewoda.

While you have a break in the skin, you should also avoid going into the water, and this includes swimming pools, hot tubs, lakes, and oceans.

Aziz says practicing basic hygiene is key.

“Wash your hands frequently with soap and water, especially before and after touching a wound or changing a bandage,” she advises.

You can also use antiseptic cream on larger wounds to help prevent infection.

Takeaway

Necrotizing fasciitis can be deadly, so if you suspect you have it, you must get it treated right away.

“Necrotizing fasciitis is an extremely dangerous illness that has to be treated quickly and aggressively since it has the potential to be lethal. However, the odds of survival and recovery are higher the earlier the treatment is initiated,” says Wojewoda.

• Cardiovascular disease deaths involving substance use increased from 1999 to 2019, even as overall cardiovascular disease deaths fell during that time.
• Alcohol was involved in 65% of cardiovascular disease deaths related to substance use, but death rates for cannabis and psychostimulants increased more sharply.
• Women, American Indian and Alaskan adults, younger adults, and rural residents also saw larger increases in cardiovascular disease deaths related to substance use.

Deaths due to cardiovascular disease that involved substance use increased an average of 4% per year from 1999 to 2019, even as overall cardiovascular disease deaths decreased during that time, a new study shows.

“The results are concerning, as they mark a significant upward trend in cardiovascular deaths where substance abuse was noted,” said Dr. Sameer Amin, cardiologist and chief medical officer at L.A. Care Health Plan, who was not involved with the new research.

“Considering this is in the midst of an overall decrease in cardiovascular death during that time period, this appears to be an exception to our progress in treating cardiac disease,” he told Healthline.

Dr. Cheng-Han Chen, interventional cardiologist and medical director of the Structural Heart Program at MemorialCare Saddleback Medical Center in Laguna Hills, Calif., pointed out that the data in the study only goes through 2019, just before the start of the COVID-19 pandemic.

“There have been data pointing out that substance use and abuse have worsened starting in 2020 with the pandemic,” said Chen, who was not involved in the new study. So “it’s concerning to think that this trend may be getting worse in more recent years.”

The study was published Jan. 10 in the Journal of the American Heart Association.

Many substances linked to cardiovascular disease

In the study, researchers used publicly available data from the Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research (WONDER) database to examine cardiovascular disease death trends from 1999 to 2019.

The rate of cardiovascular deaths related to substance use increased from 9.9 per 100,000 population in 1999 to 21.4 per 100,000 population in 2019, researchers found — an average increase of 4% per year. From 2012 to 2019, the death rate increased even more rapidly: 6.2%.

In comparison, the overall rate of cardiovascular disease deaths decreased an average of 1.5% per year, researchers found.

Several substances, such as alcohol, opioids, stimulants, sedatives and cannabis increase the risk of cardiovascular disease, including coronary heart disease, heart failure and irregular heart rhythms, the researchers point out.

Overall, 65% of the cardiovascular disease deaths related to substance use were linked to alcohol,  followed by opioids (13.7%), cocaine (9.8%), stimulants (6.5%), sedatives (4.1%) and cannabis (0.5%).

However, people who used cannabis (12.7%) and psychostimulants such as amphetamines (16.8%) had higher increases in the average annual percent change in cardiovascular disease deaths related to substance use.

“It’s troubling to see that there have been increases in cardiovascular disease mortality with all different types of substances, not only the most commonly used substance, alcohol,” Chen told Healthline.

The study did not include smoking/tobacco use as a form of substance use. Smoking is linked to heart disease, stroke and other chronic diseases, as well as lung and other cancers.

While the findings highlight long-term trends in cardiovascular disease deaths related to substance use, researchers did not have information about other risk factors for cardiovascular disease, such as a condition such as type 2 diabetes or high blood pressure or whether people had a family history of cardiovascular disease.

Who is most impacted by cardiac deaths

The new study’s findings show that certain groups were impacted more by cardiovascular disease deaths related to substance use.

For example, increases in the average annual percent change for death rates were higher for American Indian or Alaskan individuals (5.4%); people ages 25 to 59 years (5.3%); people living in rural areas (5.0%); adults ages 55 to 69 years (4.9%); and women (4.8%).

“I am particularly concerned at the disparities in outcomes for women, American Indian/Alaskan individuals and rural area residents,” said Amin. This “could represent healthcare inequities in our system.”

The death rate was higher for people living in rural areas (15.2 per 100,000) than urban areas (14.1 per 100,000). It was also higher for men (22.5 per 100,000) than women (6.8 per 100,000).

Although death rates were higher in men than in women, women saw larger increases during the study period, researchers found.

“Data from prior studies have found notable increases in substance use among women over the last 20 years, and women may face unique societal risks that may contribute to the increases noted in our study,” study author Dr. Dmitry Abramov, cardiologist and associate professor of medicine at Loma Linda University Health in Loma Linda, Calif., said in a news release.

In addition, there were differences in rates among racial and ethnic groups.

The highest death rate was among American Indian or Alaska Native adults (37.7 per 100,000), in comparison to Black adults (20.3 per 100,000), white adults (14.1 per 100,000), Hispanic adults (13.0 per 100,000) and Asian adults or Pacific Islanders (3.6 per 100,000).

Chen said understanding which groups are most affected by cardiovascular disease deaths related to substance use could help target public health efforts aimed at reducing substance use, and related health outcomes, among these groups.

In addition to trends through 2019, Amin is concerned about what has happened since then. In particular, he highlighted that there appears to be an upward trend for some groups starting around the time of the 2007-2008 financial crisis.

“If this is associated with an increase in socioeconomic inequality and a widening gap in economic disparity [between certain groups] during that time, we have to be particularly vigilant post-COVID pandemic,” he said. “The effects of the post-COVID economic environment could potentially exacerbate the gap.”

Takeaway

Researchers used data from the CDC to examine cardiovascular disease death trends from 1999 to 2019. In particular, they focused on deaths that involve substance use.

During that time, cardiovascular disease deaths involving substance use increased by an average of 4% per year — with a faster increase from 2012 to 2019 — even as overall cardiovascular disease deaths fell.

Rates of cardiovascular disease deaths involving substance use increased faster for women, American Indian and Alaskan adults, younger adults, and rural residents, as well as for those who used cannabis or psychostimulants.