Cardiovascular effects of marijuana and synthetic cannabinoids: The good, the bad, and the ugly

Dysregulation of the endogenous lipid mediators endocannabinoids and their G-protein-coupled cannabinoid receptors 1 and 2 (CB₁R and CB₂R) has been implicated in a variety of cardiovascular pathologies. Activation of CB₁R facilitates the development of cardiometabolic disease, whereas activation of CB₂R (expressed primarily in immune cells) exerts anti-inflammatory effects. The psychoactive constituent of marijuana, Δ⁹ -tetrahydrocannabinol (THC), is an agonist of both CB₁R and CB₂R, and exerts its psychoactive and adverse cardiovascular effects through the activation of CB₁R in the central nervous and cardiovascular systems. The past decade has seen a nearly tenfold increase in the THC content of marijuana as well as the increased availability of highly potent synthetic cannabinoids for recreational use. These changes have been accompanied by the emergence of serious adverse cardiovascular events, including myocardial infarction, cardiomyopathy, arrhythmias, stroke, and cardiac arrest. In this Review, we summarize the role of the endocannabinoid system in cardiovascular disease, and critically discuss the cardiovascular consequences of marijuana and synthetic cannabinoid use. With the legalization of marijuana for medicinal purposes and/or recreational use in many countries, physicians should be alert to the possibility that the use of marijuana or its potent synthetic analogues might be the underlying cause of severe cardiovascular events and pathologies.