Meth-Related HF: Challenges at the Intersection of CVD and Addiction

Methamphetamine use is on the rise around the world and so too is heart failure (HF) secondary to use of the drug, yet evidence to guide clinicians is slim and inconsistent, according to a review published last week in Heart.

Those treating the condition face a lack of information on prevalence, pathophysiology, predisposing factors, and outcomes, Veena Manja, MBBS, PhD (VA Center for Innovation to Implementation, Menlo Park, CA, and Stanford University, Stanford, CA), and colleagues note in their paper.

“Not much is known, and what we know is not compiled together. And we don’t know what the quality of the evidence we have is,” Manja told TCTMD. This review aims to address that uncertainty.

For clinicians, the level of awareness about meth HF as an entity depends on how widely the drug is being used in their particular area. “I encountered methamphetamine-associated heart failure for the first time after I moved to California,” Manja said.

“It used to be a predominantly West Coast drug,” but now, “meth is spreading rapidly across the United States,” Manja stressed, adding that diagnosis of heart failure related to its use may be lagging in regions less accustomed to the drug.

As of yet, “we don’t know what makes some people susceptible to cardiac outcomes, whereas others can use meth for years or decades and not develop any symptoms,” she said. Nor do published studies—which measure meth use in patients already diagnosed with HF—speak to the true prevalence. To get a clearer picture, researchers would need to prospectively track meth users to see what proportion develop the disease—an unrealistic scenario.

Jonathan D. Davis, MD (University of California, San Francisco), who authored an editorial accompanying the paper, commented to TCTMD that physicians who are attuned to meth HF find themselves asking: “What do you do about it?”

Prevalence is rising, yet treatment options are few, he added.

‘So Much Heterogeneity’

The researchers gathered data from 21 observational studies that were carried out between 1997 and 2020. Among them, 17 were carried out in the United States, two in New Zealand, and one each in Australia and Germany. Mean patient age in the reports ranged from 35 to 61 years, and the proportion of men ranged from 57% to 99%.

Studies were inconsistent in what outcomes they tracked, how they quantified meth use, and what demographic information they recorded. Indeed, Davis notes in his editorial, “a pivotal finding of this analysis was the existence of so much heterogeneity between trials that they could not perform a meta-analysis.”

Route of administration was most often inhalation/smoking, and the studies tracked use ranging in frequency from daily to every other week. Total monthly doses in the reports ranged from 0.35 grams up to 24.5 grams. Among the meth users, the average duration of use before their heart failure diagnosis was 5 years, one study found, and for nearly 20% the diagnosis came within the first year.

Not much is known, and what we know is not compiled together. Veena Manja

Meth users who developed heart failure tended to be older than those who did not, but also tended to be younger than the general heart failure population. Occurrence of meth-related heart failure was variously linked among the studies to other substance abuse, homelessness, posttraumatic stress disorder, depression, and other types of heart and kidney disease.

Data on race/ethnicity were limited. One study showed Asian-Pacific Islanders and African Americans were more likely than white people to develop meth HF, for example. Another, however, showed that white people and African Americans had a disproportionately higher prevalence of meth HF compared with Latino individuals. In the New Zealand-based study, patients with methamphetamine-associated cardiomyopathy were more likely to be of Māori descent in comparison to patients with other forms of cardiomyopathy.

Meth HF was associated with severely reduced LVEF, especially among men, Manja et al note. Most patients presented in NYHA class III/IV.

After hospital discharge, two-thirds of patients were “clinic no shows” and the mean time to medication refill was 5 months. They were more likely to be readmitted than patients with atrial fibrillation, and many returned within 3 months after their hospital stay.

However, once baseline demographics were accounted for, patients with meth HF were no more likely than patients with other forms of heart failure to die. Discontinuing meth use appears to lead to LV remodeling and improved functional status.

“Continued use resulted in persistent severe LV dysfunction and dilatation, more HF rehospitalizations, longer hospital stay, higher likelihood of NYHA class III or IV HF at follow-up, and higher all-cause mortality,” the researchers note.

Harm Reduction, Team-Based Care

Manja said that, until recently, her main approach to treating patients with meth HF was to tell them meth is contributing to their heart disease and that they need to quit, then refer them to an addiction specialist. But, as their review showed, many patients never take that next step.

“Heart failure is a difficult disease to live with. It [involves] strict fluid and salt restrictions. There are several medications several times a day. So patients usually need social support to be successful in treatment of heart failure,” she explained. This is even harder to accomplish for a person with meth HF, who’s facing addiction and oftentimes other challenges like homelessness.

Moreover, “there is so much stigma” surrounding meth HF, but this can be reduced by helping clinicians understand the many sociodemographic factors that lead people to start using the drug in the first place and make it hard to stop, she suggested. Unlike other substance use disorders, “the problem with meth is there is no pharmacological treatment, so there is no easy fix. It has to be behavioral therapy, contingency management.”

One of her patients with meth-associated HF was able to quit for a time, but then saw his addiction return when “he lost his social circle,” Manja recalled. “Everybody in his social circle did meth. So he was more miserable off the meth without his friends to interact with” than he was when facing heart failure.

Harm reduction, rather than abstinence, is a useful strategy when treating meth HF, as is empathy, she noted. “You work with the individual to try and decrease the harms caused by substance use. You do not come from a judgmental stance, where you say, ‘You are doing yourself harm and you must stop this or you will not get better.’ . . . Maybe the patient’s not at a point where he can hear that or work with that.”

It also would be helpful to integrate treatments for heart failure and meth addiction into a single setting where patients can get all the care they need, Manja said.

In his own work, Davis has pursued this comanagement approach: he created the Heart Plus Clinic, a joint HF and addiction medicine facility in San Francisco for patients with these overlapping conditions. “People that stereotypically use stimulants and have heart disease, they’re in the emergency room and  hospital over and over and over again. They leave, they don’t come to clinic, they come right back,” he said, and there is frustration among cardiologists when patients don’t take necessary HF meds.

Their clinic recruits patients who’ve been recently hospitalized, who then come in twice weekly to meet with an addiction specialist and cardiologist. This is paired with contingency management, “a psychological tool to reinforce the positive behavior,” Davis said.

“What we do is there’s a fishbowl with 500 tickets, and half the tickets say, ‘Good job, congratulations,’ and half the tickets are worth a monetary prize from $5 to up to $100. So every time they show up to clinic, they get to draw from the fishbowl. And the more times they come in a row, they get to draw more times.” Also, each visit they do a urine drug screen, with consecutive negative results translating into more trips to the fishbowl.

This approach to care has led to an uptick in clinic visits and a plummet in trips to the emergency room, which from a systems perspective is important, said Davis. And there have been secondary benefits such as connecting patients to social services and combating preconceived ideas among staff that these individuals can’t get better.

“You can really leverage all the good things of cardiology and the good things of addiction medicine, but you’re doing it in a partnered way. . . . By linking the two for the patient, and showing that ‘We care about you and want you to get better,’ it’s that multidisciplinary approach that has really been able to make a meaningful difference in how they feel about their disease and feel about their health,” he emphasized.