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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 31, No 5, September/October 2020
AFRICA
243
The effect of heroin use on cardiac function has been
investigated in several studies previously. It was demonstrated
in the study by Pons Llado
et al.
on patients using IV heroin
that heroin use had no effect on left ventricular systolic or
diastolic function, but significantly increased the rate of mitral
and tricuspid valve abnormalities.
5
In another study, it was
demonstrated that synthetic cannabinoids negatively affected
left ventricular function, whereas heroin did not.
6
However, these
studies do not provide any information on the effect of heroin
addiction on right ventricular function.
Although heroin use does not seem to have any effect on left
ventricular function, according to the results of these studies,
others have demonstrated atrial and myocardial irregularities by
histopathological sampling.
7
Orlando
et al
. reported a subclinical
reduction in the ejection fraction of the left ventricle in 20
heroin addicts.
8
In another case report, cardiogenic shock was
reported in a young heroin addict, which was related to severe
depression of left ventricular contractility. However, the authors
attributed this to another cause, right ventricular failure.
9
All
these conflicting results suggest the need for further studies.
The cardiac effects of heroin are not limited to myotoxic
effects. It was reported in the study by Pavlidis
et al.
that
myocardial infarction was observed rarely, but the mechanism is
unknown. Increased cardiac weight, which is observed as a result
of increased thickness of the cardiac walls, could be a factor and
therefore should be investigated.
10
In another case of heroin-related cardiac crisis, the authors
attributed it to heroin-related cardiotoxic effects and vasospasm.
11
Furthermore, in studies investigating the mechanism of heroin-
related arrhythmias and subsequent sudden death, it was
demonstrated that heroin use did not only lead to myocardial
infiltration, but also to fibromuscular dysplasia in the sinus
and atrioventricular nodes, in the transmission pathways and
to fat infiltration. They concluded that this may be the cause of
arrhythmia-related sudden death in heroin addicts.
12,13
Another important heroin-related problem is pulmonary
oedema, which was demonstrated as one of the most frequent
causes of heroin-related death. There are many studies in the
literature on the subject,
3,14,15
however, the mechanism could not
be clearly defined. Although the direct pulmonary effects have
been primarily considered, depression in cardiac contractility has
been suggested as a possible mechanism.
In order to better understand the mechanism of pulmonary
oedema, which is an important problem in heroin addicts, the
cardiac effects of heroin should be defined. However, when heroin
is used via the IV route, it is administered together with additional
chemical substances named adulterants (acetaminophen,
caffeine, diphenhydramine, methorphan, alprazolam, quetiapine,
chloroquine, diltiazem, cocaine, procaine, lidocaine, quinine/
quinidine, phenacetine and thiamine), and the potential cardiac
effects of these substances complicate evaluation of the cardiac
effects of heroin.
16
Therefore in order to investigate the cardiac
effects of heroin only, we excluded patients using heroin via the
IV route.
This study demonstrated that heroin use significantly
increased right ventricle and pulmonary artery diameters,
and negatively affected the MPI and RVIVA. Assessing right
ventricular performance is not easy and is underestimated in
many studies. Generally, evaluation of more than one parameter
is recommended.
17
Being a pilot study on the subject, our study
is important, since it shows impairment in multiple parameters.
However, it is notable that values such as TDI-S and TAPSE
were unaffected. Further studies with larger sample sizes,
using new techniques such as three-dimensional and strain
echocardiography are needed to better define the subject.
Our study had some limitations; these were the single-centre
design and lack of examinations such as three-dimensional and
strain echocardiography during cardiac function investigations.
Also this was a retrospective, observational study therefore it
does not provide conclusive results in this regard.
Conclusion
Heroin addiction, which is an important public health problem,
negatively affects right ventricular function and more attention
should be paid to the cardiac function of these patients. Since
present knowledge on the effect of heroin use on cardiac
function is limited, this study is important for its contribution to
the literature. However, further studies with a larger sample size
are needed for clearer results.
References
1.
Hosztafi S, Fürst Z. Therapy in heroin addiction.
Neuropsychopharmacol
Hung
2014;
16
(3): 127–140.
2.
Demaret I, Lemaître A, Ansseau M.
Heroin Rev Med Liege
2013;
Table 2. Echocardiographic features of the groups
Variables
Heroin (+)
Heroin (–)
p
-value
RVEF (%)
59.6
±
2.5
60.6
±
2.3
0.08
Intraventricular septum (mm)
8.7
±
1.3
8.6
±
0.9
0.79
Right atrium area (mm
2
)
16.2
±
2.9
14.9
±
2.6
0.04
RV basal diameter (mm)
39.4
±
4.7
35.6
±
4.3 < 0.01
RV mid diameter (mm)
37.2
±
4.7
31.8
±
3.6 < 0.01
RV apicobasal (mm)
60.8
±
7.2
53.6
±
11.1
0.01
Pulmonary artery diameter (mm)
22.4
±
2.5
20
±
2.5 < 0.01
RV wall thickness (mm)
4.7
±
1.1
4.6
±
1
0.81
RVFAC (%)
42.7
±
8.3
43.9
±
3.5
0.44
TAPSE (mm)
24.1
±
4.2
24.5
±
2.4
0.71
Pulsed Doppler MPI
0.48
±
0.22
0.39
±
0.11
0.02
Tricuspid PW E (cm/s)
62.9
±
14.8
52.6
±
12
0.01
Tricuspid PW A (cm/s)
44.1
±
11.4
40.7
±
8.2
0.12
Tissue Doppler S wave (cm/s)
13.7
±
2.1
13.8
±
2.1
0.86
Tissue Doppler e wave (cm/s)
17.2
±
4.5
14.3
±
3
0.01
Tissue Doppler a wave (cm/s)
12.6
±
3.1
13.1
±
3.1
0.50
RVIVA (m/s
2
)
2.92
±
0.69
3.4
±
0.68 < 0.01
p
< 0.05 statistically significant. Continuous variables are reported as mean
±
SD or median (IQR). Categorical variables are reported as
n
(%).
RVEF: right ventricular ejection fraction, TAPSE: tricuspid annular plane
systolic excursion, RVFAC: right ventricular fractional area change, MPI:
myocardial performance index, RVIVA: right ventricular isovolumic accelera-
tion, PW: pulsed wave.
Table 3. Multiple logistic regression analysis to detect
independent factors related to heroin-using group
Variables
Univariate
OR,95% CI
p-
value
Multivariate
OR,95% CI
p-
value
RVIVA (m/s
2
)
0.36 (0.18
–
0.72) < 0.01 0.42 (0.19
–
0.88)
0.02
Pulsed Doppler MPI 16.4 (1.12
–
239.27)
0.04 9.45 (0.51
–
172.1)
0.13
Pulmonary artery
diameter (mm)
1.49 (1.19
–
1.85) < 0.01 1.43 (1.14
–
1.81) < 0.05
MPI: myocardial performance index, RVIVA: right ventricular isovolumic
acceleration.