Paroxysmal Sustained Ventricular Tachycardia with Cardiac Arrest and Myocardial Infarction in 29-Year-Old Man Addicted to Medical Marijuana—It Never Rains but It Pours

Round 1

Reviewer 1 Report

The central thesis of the argument relies on the patient's addiction to medical marijuana. However, the authors do not show any evidence to support this diagnosis. There is no indication of a substance use disorder, no discussion of other substance use- illicit, recreational, or prescribed. There is no frequency or dosage of medicinal marijuana for the underlying conditions (anxiety, depression). 

There is a literature to support a relationship between marijuana inhalation and tachycardia and atrial fibrillation, to which the current work is well aligned. Any discussion of addiction, however, needs to be removed unless there is supportive diagnostic criterion.

Author Response

The central thesis of the argument relies on the patient's addiction to medical marijuana. However, the authors do not show any evidence to support this diagnosis. There is no indication of a substance use disorder, no discussion of other substance use- illicit, recreational, or prescribed. There is no frequency or dosage of medicinal marijuana for the underlying conditions (anxiety, depression). 

This information was added to the article

There is a literature to support a relationship between marijuana inhalation and tachycardia and atrial fibrillation, to which the current work is well aligned. Any discussion of addiction, however, needs to be removed unless there is supportive diagnostic criterion.

This information was added to the article.

Reviewer 2 Report

Thank you for the opportunity to review your manuscript that reports a rare case of a young male mixed anxiety and depressive disorder patient with paroxysmal ventricular tachycardia who was under medical marijuana treatment.

Major concerns:

1. It was great the author listed the marijuana application in the clinic, but the introduction should add more detailed information about the prevalence of marijuana-induced cardiovascular events, especially various types of cardiac arrhythmias.

2. The author mentioned in the introduction, "It should be remembered that the regular use of marijuana has its side effects.” Please clarify how to define the regular use and overdosage during the treatment and what should be the standard medical marijuana treatment dosage for mixed anxiety and depressive disorder.

3. As the author discussed in the manuscript that paroxysmal VT in young people is a rare phenomenon that may be caused by complex etiology. The marijuana use history can not fully support that the patient’s myocarditis/ VT was induced by drugs. Did the author have more examination results for differential diagnosis? 

4. Line 190-192: The statement is inconsistent with the previous clinical finding in the case report, the patient's ECG results showed no ST-segment elevation, please revise it accordingly in the discussion. 

5. The final diagnosis of the patient is unclear in this case report. The title is confusing and needs to be simplified.

Minor concerns:

The report contains valuable information, but the language has not been well polished. Some sentences are bad in grammar and ambiguous in expression. Some examples where the language could be improved include:

Line 44-48: “29-year-old male patient, manual worker, …, with mixed anxiety and depressive disorder treated with medical marijuana .. for around 3years had been suffering from paroxysmal hemodynamically unstable ventricular tachycardia (VT).” 

Line 58-60: “He received metoprolol in extended release drug formulation (metoprolol succinate) of 25 mg q.d. due to intolerance of higher doses because of tendency to have low blood pressure, potassium…”

Line 137-139: “the patient was admitted to our cardiology center … with recurrent VT in which some VT were interrupted with an antiarrhythmic therapy of the ICD…”

Line 169-172, Line 177-178

The current phrasing makes comprehension difficult. The English language should be improved to ensure that an international audience can clearly understand your text.

Author Response

Major concerns:

1. It was great the author listed the marijuana application in the clinic, but the introduction should add more detailed information about the prevalence of marijuana-induced cardiovascular events, especially various types of cardiac arrhythmias.

This information was added to the article.

2. The author mentioned in the introduction, "It should be remembered that the regular use of marijuana has its side effects.” Please clarify how to define the regular use and overdosage during the treatment and what should be the standard medical marijuana treatment dosage for mixed anxiety and depressive disorder.

There is no fixed dose. Dosing is individual. Information on addiction assessment is added to the paper.

3. As the author discussed in the manuscript that paroxysmal VT in young people is a rare phenomenon that may be caused by complex etiology. The marijuana use history can not fully support that the patient’s myocarditis/ VT was induced by drugs. Did the author have more examination results for differential diagnosis? 

You are perfectly right. The cause and effect relationship between marijuana use and myocarditis is hard to prove. Even myocardial biopsy yields inconclusive results. We adopted it from previous case studies based on probability.

4. Line 190-192: The statement is inconsistent with the previous clinical finding in the case report, the patient's ECG results showed no ST-segment elevation, please revise it accordingly in the discussion. 

It is corrected.

5. The final diagnosis of the patient is unclear in this case report. The title is confusing and needs to be simplified.

It is corrected.

Minor concerns: They are addressed.

Round 2

Reviewer 1 Report

I was surprised to find the patient had a confirmed cannabis use disorder. This work has major implications in cardiology as well as psychiatry.

Author Response

Thank You for Your appreciation. We had it ‘worked out’ from the beginning but did not present in a right manner. Thank You again for Your valuable remarks.

Reviewer 2 Report

Thank you for providing the epidemiologic information in the introduction part. However, to get rid of potential plagiarism issues, please rephrase and summarize the following sentences which are exactly copied from the cited paper "compared with never users had more supraventricular tachycardia/day (adjusted geometric mean ratio [GMR] 1.42, 95% confidence interval [CI], 0.87-2.32), more... Additionally, more frequent marijuana use was associated with more runs of non-sustained VT/day (GMR 1.56, 95% CI 1.13-2.17)". https://www.ajconline.org/article/S0002-9149(22)00541-0/fulltext 

Author Response

Thank You for Your crucial remark. We have rephrased this part.