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It should also be stressed that although this adverse event seems to be quite “benign” in young healthy subjects, it is apparently more “malignant” in older patients having other risk factors for thromboembolism. The exact incidence of AF related to marijuana smoking is difficult to be estimated. Given the euphoric and neuropsychological effects of marijuana that may alter or cover palpitations or other symptoms suggestive of AF, this issue becomes more complicated. It should also be borne in mind that due to social or legal reasons, most users of illicit drugs avoid seeking medical attention. In addition, many short episodes of AF may pass unnoticed. Taking into consideration all these notions, it could be reasonable to conclude that the burden of the problem is possibly underestimated. Panagiotis Korantzopoulos, MD, PhD Ioannina, Greece 30 December 2013

1. Thomas G, Kloner RA, Rezkalla S. Adverse cardiovascular, cerebrovascular, and peripheral vascular effects of marijuana inhalation: what cardiologists need to know. Am J Cardiol 2014;113:187e190. 2. Korantzopoulos P, Liu T, Papaioannides D, Li G, Goudevenos JA. Atrial fibrillation and marijuana smoking. Int J Clin Pract 2008;62: 308e313. 3. Krishnamoorthy S, Lip GY, Lane DA. Alcohol and illicit drug use as precipitants of atrial fibrillation in young adults: a case series and literature review. Am J Med 2009;122: 851e856.e3. http://dx.doi.org/10.1016/j.amjcard.2014.01.001

Adverse Cardiovascular, Cerebrovascular, and Peripheral Vascular Effects of Marijuana: What Cardiologists Need to Know We read the recent report Adverse Cardiovascular, Cerebrovascular, and

Peripheral Vascular Effects of Marijuana: What cardiologists need to know by Thomas et al.1 The investigators summarized the literature concerning the adverse vascular effects of marijuana, the most widely used illicit drug in the world. We would like to point out an omission in the review. In 2013, we published a study of 160 patients with ischemic stroke and transient ischemic attack aged 18 to 55 years and 160 age-, gender-, and ethnicitymatched control patients without cardiovascular or neurologic diagnoses.2 Cases and controls had urine screens for cannabis within 72 hours of hospital admission. Twenty-five patients (15.6%) with stroke and transient ischemic attack had positive cannabis drug screens. Thirteen control participants (8.1%) had positive cannabis screens. Cannabis use was associated with increased risk of ischemic stroke and/or transient ischemic attack in a logistic regression analysis adjusted for age, gender, and ethnicity (odds ratio 2.30, 95% confidence interval 1.08 to 5.08). However, an association independent of tobacco has not been confirmed as all but one of the patients who tested positive for cannabis also used tobacco. Finding an association is not the same as finding causality. However, we agree that it is important for cardiologists and other physicians caring for patients with vascular disease to be aware of this potential association. We suggest that younger patients presenting with acute cardiac and cerebral ischemia are screened for cannabis, particularly in cases when there are no other vascular risk factors. Those patients with positive screens could then be informed of a potential association between cannabis and vascular disease and be counseled

against further use. The wave of decriminalization of cannabis use in the United States and elsewhere in the world makes it imperative that further research is undertaken to clarify the relation between cannabis and vascular disease. Peter Alan Barber, PhD Sally Roberts, MBChB David A. Spriggs, MBChB Neil E. Anderson, MBChB Auckland, New Zealand 23 January 2014

1. Thomas G, Kloner RA, Rezkalla S. Adverse cardiovascular, cerebrovascular, and peripheral vascular effects of marijuana inhalation: what cardiologists need to know. Am J Cardiol 2014;113:187e190. 2. Barber PA, Pridmore HM, Krishnamurthy V, Roberts S, Spriggs DA, Carter KN, Anderson NE. Cannabis, ischemic stroke, and transient ischemic attack: a case-control study. Stroke 2013;44:2327e2329. http://dx.doi.org/10.1016/j.amjcard.2014.01.400

Erratum for Soufras et al. “Relation Between White Blood Cell Count and Infarct Size: What About Differential?” Am J Cardiol 2014;113:412 Re: Soufras GD, Hahali G, Kounis NG. Relation between white blood cell count and infarct size: what about differential? Am J Cardiol 2014 Jan 15;113(2):412 Should be changed to: Re: Soufras GD, Hahalis G, Kounis NG. Relation between white blood cell count and infarct size: what about differential? Am J Cardiol 2014 Jan 15;113(2):412 http://dx.doi.org/10.1016/j.amjcard.2014.01.003

Adverse cardiovascular, cerebrovascular, and peripheral vascular effects of marijuana: what cardiologists need to know.

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