Amal Mattu, MD
DISCLOSURES November 21, 2025
During a recent shift, I cared for a 28-year-old man who presented to the emergency department (ED) with chest pain. He described the pain as sharp, midsternal, and associated with nausea, dyspnea, and diaphoresis. The symptoms had been persistent for 90 minutes and began at rest. He had no known history of medical issues or cardiac risk factors, including family history of premature coronary disease. His social history was only positive for increasing marijuana (smoking and edibles) use over the past 5 years, now typically four to five times per week. Aside from looking uncomfortable and mildly diaphoretic, his vital signs and exam were nondiagnostic. An ECG was obtained and showed evidence of an acute anterior ST-segment myocardial infarction (STEMI) with reciprocal ST-segment depression in the inferior leads.
The interventional cardiologist was immediately contacted. He expressed disbelief that a 28-year-old man with no known cardiac risk factors could be experiencing a STEMI, but after reviewing the ECG for himself he admitted that he “had no other choice but to do the cath.” The patient was given aspirin, ticagrelor, and heparin, and he was quickly taken to the cardiac catheterization lab.
Later during my shift, the cardiologist called me back with follow-up: the patient had critical blockage of the left anterior descending artery (LAD) as well as a 30%-40% blockage in the right coronary artery. The patient received a drug-eluting stent in the LAD and was doing fine in the coronary care unit. What was the patient’s risk factor for the development of coronary artery disease at such a young age?
Cannabis and Hidden Cardiovascular Risk
Research in recent years has consistently shown a concerning association between the use of cannabis products and the development of atherosclerotic disease with acute complications. Some of the early studies, however, suffered from confounding factors such as preexisting cardiac risk factors and tobacco use.
The authors of a more recent study, published in JACC, sought to determine the long-term cardiovascular risk of cannabis use in healthy individuals. They performed a retrospective study using data from a national health research network, focusing specifically on patients aged 50 years and younger. They compared a “cannabis-user group” with a “noncannabis-user group” — both groups of individuals were free of significant traditional cardiac risk factors. After propensity score matching, they were able to compare nearly 90,000 patients in each group with balanced demographics and baseline health characteristics.
The results of the study confirmed what multiple recent studies have shown: cannabis users had a higher risk of myocardial infarction (MI) and a lower survival probability. The authors’ findings also corroborated what had been found in other studies: the cannabis group had a higher risk for ischemic stroke, heart failure, major adverse cardiovascular events, and all-cause mortality. The authors concluded that “cannabis use appears to pose a substantial and independent risk [for adverse cardiovascular events], even in a population without traditional cardiovascular risk factors.”
Implications for Clinical Practice
The case I described at the start of this Viewpoint, unfortunately, is not a rarity. In recent years, there has been an increasing number of cases of young patients with MI who are frequent cannabis users without any other apparent cardiac risk factors. The case I describe is the fourth in the past 3 years of which I am aware. When I first read the literature on this topic in 2019, I was quite surprised to see that the use of marijuana (the most frequently used cannabis product) was associated with increases in blood pressure and tachydysrhythmias. I had assumed that marijuana would “quiet” the cardiovascular system, but it actually does just the opposite.
Early reports suggested increased risk for atrial fibrillation and ventricular dysrhythmias, as well as increased risk for stroke, MI, congestive heart failure, and sudden death. Studies also suggested a nearly fivefold increased risk for MI in the first hour after smoking marijuana. Recent studies have also demonstrated an increased risk for stroke as well as venous thromboembolism, highlighting not only the adverse cardiac effects of cannabis products but also adverse vascular effects throughout the body.
Endothelial Dysfunction Seen in Smokers and Edible Users Alike
As this literature was being produced and concerns were being raised about potential adverse cardiovascular effects of cannabis products, there was some pushback from those who thought the primary adverse effects of these products, more specifically marijuana, were from the toxic chemicals and particulates associated with smoking.
However, a study published earlier this year compared various markers of endothelial dysfunction (which is associated with accelerated development of atherosclerosis) in chronic marijuana smokers vs chronic consumers of tetrahydrocannabinol (THC). “Chronic use” was defined as consumption of cannabis in either form at least three times per week for at least 1 year. The researchers found that the indicators of endothelial dysfunction between the marijuana smokers vs the edible consumers were equal, and that the magnitude of endothelial dysfunction in either group was equal to that found in chronic cigarette smokers.
Translating Research Into Patient Care
How should we apply this information? I suggest that there are two things that we all must do:
First, I have found that research and publications pertaining to the adverse cardiovascular effects of cannabis products is one of the hottest topics in the cardiology literature. Despite this, information has not spread to the lay public. Therefore, we need to warn our patients of the cardiovascular risks involved in using these products. This is no different than how we warn our patients about the health risks associated with smoking cigarettes, drinking alcohol to excess, or eating junk food.
Second, as recreational use of cannabis increases, whether via smoking marijuana or consuming edibles, I anticipate that in the coming years we will see increasing numbers of young patients without “traditional” risk factors presenting with MI, stroke, or venous thromboembolism. Therefore, we should add cannabis consumption to the list of cardiac risk factors that we elicit from patients, and we must make sure that we are not discounting our concerns purely because of the patient’s age.
Amal Mattu, MD, is a professor, vice chair of education, and co-director of the emergency cardiology fellowship in the Department of Emergency Medicine at the University of Maryland School of Medicine in Baltimore. Follow Dr Mattu on X.
