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Official websites use. Share sensitive information only on official, secure websites. To whom correspondence should be addressed. E-mail: sivanritt yahoo. This is an open-access article. Arabs are a large minority group in the Israeli society. With the increasing use of medical cannabis throughout Israel due to changing governmental policies, the interactions of the Arab society with medical cannabis becomes of scientific and medical relevance. Recreational cannabis use is considered haram forbidden in Islam. However, most religious scholars agree that medical cannabis usage might be justified as zarurat emergency and life-saving, therefore allowed use. There are few Arabic-speaking web-based medical-cannabis support groups, and little official information about it is available in the Arabic language. Informed consent can only be obtained when patients are advised in a clear and understandable language which treatment options are available, as well as their alternatives, risks, prospects, and potential side effects, including those relating to refraining from treatment. Accessibility to information, especially online information gathering, has the potential of fostering greater patient engagement in health maintenance and care. Without resources in a language that patients can read and understand, they cannot achieve the proper health literacy necessary to maintain good health, to make wise health decisions, and to make wise use of health services. The instruction also recommends additional recruitment of professionals from diverse minority background. New unpublished data co-author R. This information demonstrates the gap in MCT-seeking patients for the Arab population when compared to the Jewish population living in relative proximity to them. Cannabis al-qinnab al-hindi in Arabic was introduced into the Middle East mainly from India via Persia; the Greek physicians were familiar with the medicinal properties of the plant and incorporated the plant into their practice. Medical cannabis therapy was practiced by scholars in the medieval Islamic world; however, during the eighteenth and nineteenth centuries the cultivation and use of cannabis were prohibited. A seventeenth-century pharmacopeia written by al-Intaqui prescribed cannabis for a number of somatic ailments, but also pointed out its euphoric and lethargic effects. This contrasts sharply with recreational use, for its intoxicating and inebriating properties. These combined factors may deter Muslim patients from considering or seeking MCT as a treatment option. The predominant intoxicating cannabinoid is THC. Consumption by inhalation of intoxicating cannabinoids is commonly associated with smoking, which is generally associated with recreational prohibited use haram. As stated above, this stereotypical association could deter Muslim and Arab patients from seeking MCT. Concurrently, it is important to note the increasing number of characterized cannabinoids, 14 , 15 and the growth in advanced research for future medicinal applications. Despite the intoxicating properties of THC, there are other major cannabinoids that are non-intoxicating and which also offer medical benefits. Cannabidiol, for example, is a much investigated and characterized cannabinoid and has been reported to relieve several medical conditions associated with chronic pain and various inflammatory disorders. Moreover, some of the reviewed studies found that CBD reduced anxiety or psychosis-like effects of THC, and blunted some of the impairments of emotion and reward processing. There is an urgent need to develop standardized, consistent, and stable cannabinoid-based products. The FDA has committed to assist in facilitating and preserving incentives for clinical research. Some CBD products are being marketed with unproven medical claims and are of unknown quality. It is currently illegal to market CBD by adding it to a food or labeling it as a dietary supplement; the FDA has seen only limited data on CBD safety, which points to real risks that must be considered before taking CBD for any reason. It is therefore a challenge for the evolving medical cannabis industry MCI to develop evidence-based safe products free of pollutants and of contaminants 17 , 21 — 23 that have a positive clinically significant effect. Another challenge the MCI faces is the development of a variety of administration routes that do not involve smoking, thereby addressing some of the associated stigma and bias issues. However, it is noteworthy that these products do not always meet the quality standards acceptable by the pharmaceutical industry. These products should also be supported by valid clinical studies proving their safety and efficacy. The growth and survival of MCI relies on developing novel products that address different patient needs. Addressing these needs, including improving appropriate communication, will help both care-givers and patients who are reluctant to seek MCT due to social or religious banning to feel more comfortable, by providing an acceptable mode of administration and high-quality information in the Arabic language for the benefit of unilingual Arabic speakers. Concurrent with the Zeitgeist, patients nowadays form communities, support-groups, and associations organized mainly on social networks. These communities are active in the Hebrew language, which is one of the official languages in Israel. It is the language spoken by most of the population in Israel. In terms of public health this warrants both attention and action. Patients who actually seek online information, communal support, and interaction to ease their worries, but only speak Arabic, do not have available resources or social platforms to turn to. Cannabis use in Israel is spreading. However, due to language and cultural barriers, cannabis use by the Arab minority population is limited. In order to encourage better participation in the Israeli healthcare system by Arab-speaking citizens, it is necessary to provide patients with better access to Arab-language web-based health information. It is important to differentiate between its forbidden by both secular Israeli law and Islamic religious law , recreational use, and its medical use, the latter of which can be justified as emergency use. The government should develop programs for Arab-language information regarding medical cannabis. This will allow diversification of the patient base and equal access by all population sub-groups. Conflict of interest: No potential conflict of interest relevant to this article was reported. As a library, NLM provides access to scientific literature. Rambam Maimonides Med J. Find articles by Dror Robinson. Sivan Ritter , D. Find articles by Sivan Ritter. Lilach Zadik-Weiss , M. Find articles by Lilach Zadik-Weiss. Hadile Ounallah-Saad , Ph. Find articles by Hadile Ounallah-Saad. Nour Abu-Ahmad , D. Find articles by Nour Abu-Ahmad. Rashid Kashkoosh , M. Find articles by Rashid Kashkoosh. Mustafa Yassin , M. Find articles by Mustafa Yassin. Reuven Or , M. Find articles by Reuven Or. Collection date Jan. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel.

Medical Cannabis - Best Doctors in Ashdod

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Cannabis use is known to be associated with significant cardiovascular morbidity. We describe three cases of cannabis-related malignant arrhythmias, who presented to the cardiac department at our institution within the last 2 years. All three patients were known to smoke cannabis on daily basis. Case 1: A year-old male, presented with recent onset of palpitations. During an inpatient exercise treadmill test ETT he developed polymorphic ventricular tachycardia VT , which converted spontaneously to supraventricular tachycardia SVT in the recovery phase of the test. Subsequent risk stratification with cardiac magnetic resonance imaging and coronary angiography showed no abnormalities and an electrophysiological study was negative for sustained VT, however, SVT was easily induced with rapid conversion to atrial fibrillation. The patient successfully stopped smoking all tobacco products including cannabis and was treated with beta-blockers, with no further episodes of arrhythmia. Case 2: A year-old male presented to the Emergency Department with palpitations, chest pain, and dizziness that improved during exertion. Case 3: A year-old male presented with two episodes of syncope. Baseline examination was normal, with an ECG showing a low atrial rhythm. Interrogation of his implantable loop recorder showed episodes of early morning bradycardia episodes with no associated symptoms. Cannabis-related arrhythmia can be multiform regarding their presentation. Therefore, ambiguous combinations of arrhythmia should raise suspicion of underlying cannabis abuse, where clinically appropriate. Although causality with regards to cannabis use cannot be proven definitively in these cases, the temporal relationship between drug use and the onset of symptoms suggests a strong association. Learning points Serious adverse effects associated with cannabis use are rare and include combination of arrhythmias and conduction disturbances. A combination of different types of arrhythmias in young patient with normal heart should raise a suspicion of cannabis use. Cessation of cannabis use is crucial to cure those arrhythmias. In times when cannabis use is increasing worldwide health care professionals should be familiar with its proarrhythmic effects. Cannabis is one of the oldest plants described in ancient Greek literature for its mind-altering properties and later on for its health benefits such as achievement of local haemostasis and tapeworm eradication using the plants leaves, anti-inflammatory and analgesic effects of seeds extract. However, there is a rising concern regarding cannabis-related adverse effects such as psychosis, 2 increased incidence of acute myocardial infarction MI , 3 uncontrolled hypertension, 4 and cardiac rhythm disturbances. In our study, we will focus on the proarrhythmic effects of cannabis, discuss its possible mechanisms, and present several cases from our clinical practice. This is mediated by a biphasic and dose-dependent effect with sympathetic activation leading to tachycardia and an increase in cardiac output and blood pressure at low or moderate doses of the drug; however, parasympathetic activation with bradycardia and hypotension can both occur with higher doses of drug exposure. In addition, a number of case reports exist on cannabis-induced sinus bradycardia, and even second- and third-degree atrioventricular block AVB. Three cannabis-related cases were identified and are described as follows. The patient recalled no associated chest pain or dizziness and had no family history of sudden cardiac death SCD or premature coronary artery disease. His past medical history was remarkable for unexplained sudden-onset syncope without prodrome, 5 years prior to his index admission, as well as a 5-year history of frequent episodes of palpitations occurring at the end of physical activity. At the time of presentation to our clinic his resting lead electrocardiogram ECG was unremarkable apart from an early repolarization pattern. The QTc was normal with no epsilon wave. Blood tests confirmed normal electrolytes and thyroid hormone levels. Transthoracic echocardiogram demonstrated non-dilated ventricles with a normal, systolic left ventricular ejection fraction and no evidence of valvular heart disease. Pulmonary artery pressures were within normal limits. The patient underwent an exercise test, which showed no evidence of either inducible myocardial ischaemia or arrhythmias during 13 min of exercise. At this point, the patient was haemodynamically stable and asymptomatic, nevertheless, following the initiation of a Valsalva manoeuver, he reverted to a regular narrow complex tachycardia of b. Subsequently, he developed AF before converting spontaneously to haemodynamically stable VT Figure 3. After 5 min within the recovery stage, his VT spontaneously converted to normal sinus rhythm. A second exercise test induced similar sustained monomorphic outflow tract VT left bundle inferior axis with transition in V2—V3 leads. Coronary angiography demonstrated normal coronary arteries. Cardiac magnetic resonance CMR confirmed normal LA dimensions, non-dilated ventricles, and no evidence of late gadolinium enhancement ruling out previous MI, myocarditis, cardiac sarcoidosis, or arrhythmogenic right ventricular cardiomyopathy ARVC. Patient 1: Exercise test, early recovery phase. Sinus rhythm followed by polymorphic ventricular tachycardia starting with ventricular premature beat. Patient 1: Exercise test, recovery phase. Conversion of ventricular tachycardia to supraventricular tachycardia during Valsalva manoeuver. Conversion of atrial fibrillation to sustained monomorphic ventricular tachycardia. The patient was then referred for electrophysiological study. A subsequent VT study with aggressive ventricular programmed stimulation, with and without isoprenaline and in washout , was performed, with no induction of VT demonstrated. We were unable to reveal dual atrioventricular AV node physiology. During ventricular pacing, supraventricular tachycardia SVT was induced with concentric atrial activation Figure 4A. It was not possible to finish the study due to incessant, differential arrhythmias. During episodes of atrial and ventricular pacing the patient developed several episodes of AF with a fast ventricular response, requiring recurrent electrical cardioversion in order to continue the study Figure 4B. He was seen in our clinic 2 months after discharge, where a third exercise stress test was undertaken again without any abnormality at maximum workload. In addition, h ambulatory ECG monitoring was unremarkable. Eighteen months after his arrhythmic presentation the patient remains well and has not smoked cannabis since. A Electrophysiological study of patient 1. Supraventricular tachycardia induced during ventricular pacing arrow shows concentric activation. B Electrophysiological study of patient 1. Supraventricular tachycardia deteriorating to atrial fibrillation during ventricular overdrive pacing. The symptoms were temporarily relieved by cycling and other physical activities. The following morning, in addition to the aforementioned symptoms, he recalled episodes of dizziness. He was initially assessed in his local urgent care centre, where his examination revealed normal vital signs, however, a lead ECG confirmed sinus rhythm with complete AVB. A subsequent ECG showed atrial flutter with variable conduction, resulting in an urgent referral to our institution. On admission, he was haemodynamically stable with an entirely normal examination. Blood tests, including electrolytes and thyroid function tests, were within normal range. Transthoracic echocardiogram confirmed normal chamber dimensions with good biventricular systolic function with no evidence of valvular heart disease. During a subsequent exercise test, in which the patient achieved a heart rate of b. A Patient 2: Type 1 second-degree atrioventricular block Wenckebach conduction with a single junctional escape beat every time when atrioventricular conduction is blocked. B Patient 2. Type I second-degree atrioventricular block. Three days after hospitalization the patient was discharged home, asymptomatic with a normal ECG. He was strongly advised to stop all illicit drug use and counselled accordingly. Unfortunately, following discharge he was lost to follow-up. A healthy year-old male, known to be a regular smoker of cannabis, was admitted to our arrhythmia clinic with a history of two, identical episodes of malignant syncope within the past year, both associated with head injury. On each occasion, whilst he was having his hair cut, he became symptomatic with dizziness leading to transient loss of consciousness. His past history was remarkable for asymptomatic sinus bradycardia. His baseline examination and blood tests were entirely normal. Urine toxicology was positive for cannabis but no other recreational drugs were detected. Stand-up tilt test, carotid sinus massage, and h Holter ECG monitoring were all normal. A computed tomography brain scan revealed no evidence of intracerebral haemorrhage or infarction and no cerebral masses. His echo study was entirely normal. The patient underwent further assessment with an implantable loop recorder ILR and was counselled with regards to smoking cessation including marijuana. During a follow-up visit he reported to smoking less marijuana single episode per week with no further episodes of syncope despite ongoing evidence of nocturnal and early morning sinus bradycardia, as recorded by his ILR. The global increase in the recreational use of cannabis remains a significant concern within the wider medical community, with recent acknowledgement of the potential to cause malignant heart rhythm disturbances. There has, however, been conflicting evidence about the association between cannabis use and arrhythmia. There is evidence to suggest that chronic cannabis use increases the incidence of important cardiovascular risk factors such as insulin resistance, dyslipidaemia, 10 and hypertension in young to middle-aged adults. Cannabis use may increase the risk of acute MI. Potential mechanisms may include an increase in heart rate and blood pressure, increase in serum carboxyhaemoglobin levels, which together result in a mismatch of augmented oxygen demand and decreased oxygen supply. However, a lower risk of in-hospital mortality and a trend towards a lower risk of AF was demonstrated. In this case series we have highlighted the variant, clinical presentations of cardiac arrhythmia in the setting of significant cannabis use. Although causality, with regards to cannabis use and the onset of arrhythmia cannot be proven definitively in these cases, the temporal relationship suggests a strong association. Catecholaminergic polymorphic ventricular tachycardia often presents during exercise in patients with a family history of SCD; in this case VT occurred after exercise. Regarding Case 3 recurrent syncope, extreme bradycardia with retrograde sinoatrial node activation from an ectopic site , the differential diagnosis included sinus node dysfunction, increased vagal tone, carotid sinus hypersensitivity, and orthostatic syncope. The exact mechanisms mediating cardiac arrhythmias in marijuana smokers are unknown although several theories exist. As shown in animal models, activation of CB1 receptor leads to sympathetic inhibition and enhanced vagal tone, bradycardia, and hypotension. Possible mechanisms of cannabis-related cardiac arrhythmias presented in Figure 7. Possible mechanisms of cannabis-related cardiac arrhythmia. Shown is a diagram of possible mechanisms of arrhythmias in cannabis users. Cannabis-related arrhythmias tend to be heterogeneous regarding their presentation. Given the increasing abuse of recreational cannabis, the potential for life-threatening, arrhythmia, even in patients with structurally normal hearts, is a growing clinical concern. Within this case series, two patients stopped smoking in entirety one of whom was lost to follow-up , whilst the last patient continued to smoke cannabis but at a significantly reduced amount. This is an important aspect of this condition, regarding cannabis use. Although causality with regards to cannabis use and the onset of arrhythmia cannot be proven definitively in these cases, their temporal relationship suggests a strong association. Slide sets: A fully edited slide set detailing this case and suitable for local presentation is available online as Supplementary data. Butrica JL. The medical use of cannabis among the Greeks and Romans. J Cannabis Ther ; 2 : 51 — Google Scholar. Association between cannabis and psychosis: epidemiologic evidence. Biol Psychiatry ; 79 : — Triggering myocardial infarction by marijuana. Circulation ; : — Cardiovascular complications induced by cannabis smoking: a case report and review of the literature. Emerg Med J ; 22 : — Johnson S , Domino EF. Some cardiovascular effects of marihuana smoking in normal volunteers. Clin Pharmacol Ther ; 12 : — An epidemiologic investigation of marijuana- and cocaine-related palpitations. Drug Alcohol Depend ; 23 : — Singh GK. Atrial fibrillation associated with marijuana use. Pediatr Cardiol ; 21 : Akins D , Awdeh MR. Marijuana and second-degree AV block. South Med J ; 74 : — Van Keer JM. Cannabis-induced third-degree AV block. Case Rep Emerg Med ; : Metabolic effects of chronic cannabis smoking. Diabetes Care ; 36 : — Alshaarawy O , Elbaz H. J Hypertens ; 34 : — Arrhythmic effects of marijuana following acute myocardial infarction. Presented at HRS. Boston, MA. Cardiac arrhythmias among teenagers using cannabis in the United States. Am J Cardiol ; : Ermakov S , Scheinman M. Arrhythmogenic right ventricular cardiomyopathy—antiarrhythmic therapy. Arrhythm Electrophysiol Rev ; 4 : 86 — Catecholaminergic polymorphic ventricular tachycardia. Circ Arrhythm Electrophysiol ; 5 : — Arrhythmias in viral myocarditis and pericarditis. Card Electrophysiol Clin ; 7 : — Postexertional supraventricular tachycardia in children with catecholaminergic polymorphic ventricular tachycardia. Case Rep Cardiol ; : 1 — 3. Cardiac sarcoidosis: state-of-the-art review. Cardiovasc Diagn Ther ; 6 : 50 — Eur Heart J ; 39 : — Brugada syndrome. The peripheral sympathetic nervous system is the major target of cannabinoids in eliciting cardiovascular depression. Naunyn Schmiedebergs Arch Pharmacol ; : — Marihuana smoking: cardiovascular effects in man and possible mechanisms. N Engl J Med ; : — Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Advertisement intended for healthcare professionals. Sign in through your institution. ESC Publications. Advanced Search. Search Menu. Article Navigation. Close mobile search navigation Article Navigation. Volume 4. Article Contents Abstract. Case presentation. Lead author biography. Supplementary material. Journal Article. Cannabis induced cardiac arrhythmias: a case series. Ella Yahud , Ella Yahud. Corresponding author. Oxford Academic. Gideon Paul. Michael Rahkovich. Lubov Vasilenko. Yonatan Kogan. Eli Lev. Avishag Laish-Farkash. Revision received:. Select Format Select format. Permissions Icon Permissions. Abstract Introduction. Cannabis , Atrial fibrillation , Atrioventricular block , Ventricular tachycardia , Electrophysiology study , Cardiac arrhythmia , Case report. Learning points. Open in new tab. Patient number. During the recovery stage of a previously unremarkable exercise treadmill test ETT , he developed polymorphic ventricular tachycardia VT that converted spontaneously to supraventricular tachycardia SVT and subsequent atrial fibrillation AF. Whilst in AF he developed further haemodynamically stable VT, which finally reverted back to sinus rhythm without intervention Coronary angiography demonstrated normal coronary arteries. Cardiac MRI excluded the presence of underlying structural heart disease. An electrophysiological study confirmed the absence of scar tissue; AF and SVT were both induced during the study but not VT Following selective beta-blocker therapy with cessation of cannabis use, a subsequent exercise test was normal without recurrence of inducible arrhythmia 2 A year-old male patient presented with palpitations, chest discomfort, and dizziness. Routine blood tests and TTE were all normal During his ETT he developed asymptomatic Mobitz I, second-degree AVB with long Wenckebach cycling; of note his target heart rate was achieved Following admission and cessation of marijuana use, his symptoms resolved and his ECG reverted back to normal sinus rhythm 3 A year-old male patient presented with two episodes of malignant syncope associated with head injury. His index ECG showed a low atrial rhythm with a heart rate of 50 b. Investigations including blood tests, TTE, stand-up tilt test, carotid sinus massage, and h Holter monitoring were all normal The patient underwent internal loop recorder implantation, with no interval evidence of further syncopal episodes despite the occurrence of multiple, significant bradycardic episodes in the early morning hours. Following regular smoking cessation counselling, the patient continued to smoke cannabis. Figure 1. Open in new tab Download slide. Figure 2. Figure 3. Figure 4. Figure 5. Figure 6. Patient 3: Retrograde sinoatrial node activation from the ectopic site. Figure 7. Google Scholar Crossref. Search ADS. Google Scholar PubMed. For commercial re-use, please contact journals. Ramkumar Satish. Niederseer David. Cassar Mark Philip. Download all slides. Supplementary data. Comments 0. Add comment Close comment form modal. I agree to the terms and conditions. You must accept the terms and conditions. Add comment Cancel. Submit a comment. Comment title. 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Citing articles via Web of Science 9. Most Read Latest Acute myocardial infarction with non-obstructive coronary artery disease due to plaque erosion treated with balloon-occluded thrombolysis. A case report of critical aortic stenosis diagnosed utilizing non-imaging continuous wave Doppler probe. Successful use of point-of-care ultrasound for an elderly patient with heart failure in a primary care setting: a case report. Right ventriculography to guide left bundle branch pacing in pacing-induced cardiomyopathy: a novel case report. Accelerated hypertension following mavacamten introduction in severe obstructive hypertrophic cardiomyopathy with hypertension: a case report. More from Oxford Academic. Cardiovascular Medicine. Clinical Medicine. Medicine and Health. Authoring Open access Purchasing Institutional account management Rights and permissions. Get help with access Accessibility Contact us Advertising Media enquiries. A year-old male presented to our institution with palpitations. Whilst in AF he developed further haemodynamically stable VT, which finally reverted back to sinus rhythm without intervention. Following selective beta-blocker therapy with cessation of cannabis use, a subsequent exercise test was normal without recurrence of inducible arrhythmia. A year-old male patient presented with palpitations, chest discomfort, and dizziness. Routine blood tests and TTE were all normal. Following admission and cessation of marijuana use, his symptoms resolved and his ECG reverted back to normal sinus rhythm. A year-old male patient presented with two episodes of malignant syncope associated with head injury. Investigations including blood tests, TTE, stand-up tilt test, carotid sinus massage, and h Holter monitoring were all normal. The patient underwent internal loop recorder implantation, with no interval evidence of further syncopal episodes despite the occurrence of multiple, significant bradycardic episodes in the early morning hours.

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