Cannabis, the hidden trigger: A case of acute myocardial infarction and recurrent electrical storm

Abstract Background Cannabis use is increasingly recognized as a trigger for serious acute myocardial infarction and malignant ventricular arrhythmias, particularly when used heavily or frequently. Proposed mechanisms include autonomic imbalance, platelet activation, endothelial dysfunction, coronary vasospasm, and oxidative stress. In the setting of delayed reperfusion, extensive myocardial injury may create a highly arrhythmogenic substrate, thereby predisposing patients to electrical storm. Case Illustration This case report describes a 45-year-old male with a history of chronic tobacco smoking and long-term cannabis use, presenting with chest pain and palpitations. Upon admission, sustained monomorphic VT was unresponsive to intravenous amiodarone, and electrical cardioversion was refused by the patient. Following intravenous lidocaine, sinus rhythm was restored, revealing anteroseptal ST-segment elevation consistent with a late-presenting STEMI. The patient initially declined PCI and subsequently developed recurrent monomorphic VT that progressed to VF. The patient given deep sedation, mechanical ventilation, continuous antiarrhythmic therapy, and repeated defibrillation. After the patient later consented to PCI, coronary angiography showed severe multivessel disease, including proximal left LAD. Successful drug-eluting stent implantation restored TIMI 3 flow, resulting in rhythm stabilization. Conclusion This case highlights the interaction between chronic cannabis use, delayed myocardial reperfusion, and ischemia-driven electrical storm. Persistent ischemia created a highly arrhythmogenic substrate, with definitive coronary revascularization proving crucial for restoring electrical stability. Acute management required repeated cardioversion, continuous intravenous antiarrhythmics, deep sedation, and a structured multimodal approach to break the vicious cycle of cannabis-related ischemia and electrical instability. Clinicians should remain vigilant for cannabis-related contributions in acute coronary syndromes complicated by life-threatening arrhythmias.