Methamphetamine Associated Cardiomyopathy

34 year old male with chest pain and shortness of breath • Xray of the Week

Figure 1. 34 year old male with chest pain and shortness of breath.

Figure 2. A and B: Axial and coronal CT with cardiomegaly due to markedly dilated heart. Right pleural effusion (blue arrow). Low EF with contrast only in RA (red arrows) and RV (orange arrow). Reflux of contrast into the IVC (green arrow) and hepatic veins (white arrow) indicates tricuspid valve regurgitation.

C: Echocardiogram apical 4 chamber view. Mitral regurgitation as evidenced by a regurgitant jet extending into the RA (yellow arrow).

Discussion:

Methamphetamine (MA) and related compounds are the most widely abused drugs in the world after cannabis. It is a psychostimulant that causes an increase in the synapse of monoamine neurotransmitters, including dopamine, norepinephrine, and serotonin [1]. Methamphetamines can be smoked, snorted, injected, or ingested orally. Methamphetamine is more potent, and its effects last longer than cocaine. Methamphetamine associated cardiomyopathy (MACM) is more common in younger age groups compared to patients with cardiomyopathy attributable to other causes. The development of MACM has been shown to be dose-dependent and amplified by repetitive use, binge pattern use, and concomitant use of other substances. Autopsy studies have shown MACM to be associated with extensive myocardial fibrosis, cellular vacuolization, and myocyte destruction [2, 3]. Cardiac complications of MA use include chest pain, hypertension, arrhythmia, aortic dissection, coronary vasospasm, cardiomyopathy, sudden cardiac death, and pulmonary arterial hypertension [2].

Figure 3. Axial (A) and coronal (B) contrast-enhanced CT images in the same patient demonstrate a dilated right ventricle containing a non-enhancing filling defect, consistent with a right ventricular thrombus. (red arrows).

Imaging Findings

Echocardiography typically shows severe multi-chamber dilatation, reduced ejection fraction (EF), mitral regurgitation (MR), tricuspid regurgitation (TR), and pericardial effusion [6-9]. Patients with MACM are also prone to developing intracardiac thrombi, with up to 33% for LV thrombus and 3.3% for RV thrombus [4, 5] (Fig. 3), with RV thrombi posing a significant risk for pulmonary embolism. Thrombus formation is driven by the triad of severe systolic stasis, drug-induced endocardial injury, and a prothrombotic state. [5]. In general, patients with MACM have significantly larger LA, LV, and RV size, lower LVEF, and a higher rate of mitral regurgitation (MR) compared to other causes of dilated cardiomyopathy [6].

Contrast-enhanced CT typically demonstrates severe biventricular dilatation and associated findings of pulmonary edema like pleural effusions or septal thickening. Contrast-enhanced CT may show a hallmark sign of severe tricuspid regurgitation: the reflux of intravenous contrast into the inferior vena cava and hepatic veins. Additionally, CT can help exclude other stimulant-related complications like aortic dissection or coronary artery calcification.

Cardiac Magnetic Resonance (CMR) remains the gold standard for tissue characterization, identifying linear mid-wall septal fibrosis, but its use is often limited in the acute phase. On CMR, the presence of late gadolinium enhancement (LGE) is a key marker of irreversible myocardial damage and predicts poor functional recovery.

In this case, there is severe tricuspid regurgitation (TR) with reflux of contrast into the inferior vena cava (IVC) and hepatic veins; pleural effusion is indicative of heart failure (Figs. 2 A, B). There is also MR visualized on the echocardiogram with a large regurgitant jet extending into the LA during systole (Fig. 2C).

Differential Diagnosis

MACM must be distinguished from idiopathic dilated cardiomyopathy, which typically occurs in older demographics and lacks the same potential for reversibility. Alcoholic cardiomyopathy presents similarly, but right heart involvement and intracardiac thrombus are often more pronounced in methamphetamine users. Viral myocarditis should also be considered, though it frequently presents with sub-epicardial LGE rather than the mid-wall or sub-endocardial patterns seen in MACM.

Management and Prognosis

The mainstay of management is complete drug abstinence, which can lead to dramatic structural and functional recovery. Treatment of MACM is aimed at the specific pathology such as anticoagulation for intracardiac thrombus and diuresis/venodilators for volume overload. Prognosis is largely dictated by the extent of myocardial fibrosis present at the time of diagnosis.

Key Learning Points

• Suspect MACM in young patients with unexplained cardiomegaly and heart failure.

• CT findings include marked multi-chamber dilatation and contrast reflux into the hepatic veins.

• Intracardiac thrombi are highly prevalent (up to 33%) and can involve both ventricles.

• Cardiac MR is superior for tissue characterization and prognostication, but CT is vital in the emergency setting.

• Cardiac recovery is highly dependent on achieving sustained drug abstinence.

References:

1. Barr, A.M., et al., The need for speed: an update on methamphetamine addiction. J Psychiatry Neurosci, 2006. 31(5): p. 301-13. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1557685/

2. Reddy, P.K.V., et al., Clinical Characteristics and Management of Methamphetamine-Associated Cardiomyopathy: State-of-the-Art Review. J Am Heart Assoc, 2020. 9(11): p. e016704 DOI: 10.1161/jaha.120.016704. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428977/

3. Karch, S.B., The unique histology of methamphetamine cardiomyopathy: a case report. Forensic Sci Int, 2011. 212(1-3): p. e1-4 DOI: 10.1016/j.forsciint.2011.04.028. Retrieved from https://pubmed.ncbi.nlm.nih.gov/21664081/

4. Janardhanan, R. and A. Kannan, Methamphetamine Cardiotoxicity: Unique Presentation with Multiple Bi-Ventricular Thrombi. The American Journal of Medicine, 2016. 129(1): p. e3-e4 DOI: 10.1016/j.amjmed.2015.08.006. Retrieved from https://www.amjmed.com/article/S0002-9343(15)00780-9/fulltext

5. Schürer, S., et al., Clinical Characteristics, Histopathological Features, and Clinical Outcome of Methamphetamine-Associated Cardiomyopathy. JACC Heart Fail, 2017. 5(6): p. 435-445 DOI: 10.1016/j.jchf.2017.02.017. Retrieved from https://pubmed.ncbi.nlm.nih.gov/28571597/

6. Ito, H., et al., A comparison of echocardiographic findings in young adults with cardiomyopathy: with and without a history of methamphetamine abuse. Clin Cardiol, 2009. 32(6): p. E18-22 DOI: 10.1002/clc.20367. Retrieved from https://pubmed.ncbi.nlm.nih.gov/19330818/

7. Neeki, M.M., et al., Frequency of Methamphetamine Use as a Major Contributor Toward the Severity of Cardiomyopathy in Adults ≤50 Years. The American Journal of Cardiology, 2016. 118(4): p. 585-589 DOI: https://doi.org/10.1016/j.amjcard.2016.05.057. Retrieved from http://www.sciencedirect.com/science/article/pii/S0002914916309602

8. Wijetunga, M., et al., Crystal methamphetamine-associated cardiomyopathy: tip of the iceberg? J Toxicol Clin Toxicol, 2003. 41(7): p. 981-6 DOI: 10.1081/clt-120026521. Retrieved from https://pubmed.ncbi.nlm.nih.gov/14705845/

9. Yeo, K.K., et al., The association of methamphetamine use and cardiomyopathy in young patients. Am J Med, 2007. 120(2): p. 165-71 DOI: 10.1016/j.amjmed.2006.01.024. Retrieved from https://pubmed.ncbi.nlm.nih.gov/17275458/

10. Voskoboinik A, Ihle JF, Bloom JE, et al. Methamphetamine-associated cardiomyopathy: patterns and predictors of recovery. Intern Med J. 2016;46(6):723-727. doi:10.1111/imj.13050 https://doi.org/10.1111/imj.13050 PubMed: https://pubmed.ncbi.nlm.nih.gov/26929061/ 

11. Koo BH, et al. Recreational Drug-induced Cardiopulmonary Injury. RadioGraphics. 2025;45(10). doi:10.1148/rg.250013 https://doi.org/10.1148/rg.250013

12. Zuern CS, Sticherling C, Krisai P, et al. Methamphetamine-associated cardiomyopathy. Eur Heart J Cardiovasc Imaging. 2024;25(4):e147. doi:10.1093/ehjci/jead320 https://doi.org/10.1093/ehjci/jead320 PubMed: https://pubmed.ncbi.nlm.nih.gov/37983477/ 

13. Hagan IG, Burney K. Radiology of recreational drug abuse. RadioGraphics. 2007;27(4):919-940. doi:10.1148/rg.274065103 https://doi.org/10.1148/rg.274065103 PubMed: https://pubmed.ncbi.nlm.nih.gov/17620470/ 

14. Pujol-López M, Ortega-Paz L, Flores-Umanzor EJ, et al. Cardiac Magnetic Resonance as an Alternative to Endomyocardial Biopsy to Predict Recoverability of Left Ventricular Function in Methamphetamine-Associated Cardiomyopathy. JACC Heart Fail. 2017;5(11):853-854. doi:10.1016/j.jchf.2017.08.009 https://doi.org/10.1016/j.jchf.2017.08.009 PubMed: https://pubmed.ncbi.nlm.nih.gov/29096799/ 

Update 2026: Dr. Jaswal is a Nuclear Medicine Resident at New York Presbyterian/ Weill Cornell Medicine.

Shama Jaswal is an International Medical Graduate, currently doing research at Mallinckrodt Institute of Radiology (MIR), Saint Louis. She aims at pursuing Diagnostic Radiology residency and poses a keen interest in research alongside academics. At MIR, she has been fortunate to work on various oncology projects including the project in which they studied how the difference in fat metabolism in both sexes can affect the cancer survival and outcome, and how this study can further improve prognosis through treatment modification. Shama is both an accomplished sprinter and singer having won several national competitions in in each discipline in India. She also has a strong passion for cooking and gardening.

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Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state-of-the-art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone he has mentored has been accepted into top programs across the country, including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson.

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