Two cases show stentless care was feasible, but cannabis causation is unproven

BACKGROUND: ST-segment elevation myocardial infarction (STEMI) in young adults is uncommon and may occur in the absence of significant underlying atherosclerotic coronary artery disease. Recent cannabis consumption has been temporally associated with acute coronary syndromes through several proposed mechanisms, including coronary thrombosis, vasospasm, endothelial dysfunction, and platelet activation. We report two cases of STEMI occurring shortly after cannabis consumption that were managed using a stentless strategy. CASE PRESENTATIONS: Case 1: A 36-year-old man with recently diagnosed Type 2 diabetes mellitus and a history of daily cannabis use presented with an inferior STEMI approximately 1 h after cannabis consumption. Coronary angiography demonstrated double culprit lesions with thrombotic occlusion of the distal right coronary artery and a large thrombus within the proximal left anterior descending artery without significant underlying angiographic atherosclerosis. A minimalist immediate mechanical intervention (MIMI) strategy consisting of manual thrombus aspiration, dual antiplatelet therapy, and therapeutic anticoagulation was performed, followed by deferred angiographic reassessment after 7 days, which demonstrated complete thrombus resolution and TIMI 3 flow without residual significant stenosis in both vessels. Case 2: A 29-year-old man with heavy tobacco use and regular cannabis and alcohol consumption presented with anterior STEMI complicated by acute heart failure. Coronary angiography revealed a high thrombus burden involving the distal left main coronary artery with thrombotic occlusion of the ostial left anterior descending artery. Revascularization was achieved using manual thrombus aspiration, intracoronary glycoprotein IIb/IIIa inhibitor administration, and balloon angioplasty without stent implantation, resulting in restoration of TIMI 3 flow. No significant residual angiographic coronary stenosis was identified. CONCLUSION: These cases illustrate the feasibility of a stentless strategy in carefully selected young patients presenting with a high coronary thrombus burden and no angiographic evidence of significant underlying coronary artery disease. Although a temporal association with cannabis consumption was observed, a causal relationship cannot be established. These observations are hypothesis-generating, and larger prospective studies are required to better define the mechanisms underlying cannabis-associated STEMI and the role of stentless management in this setting.