Though cannabis-induced cardiovascular events are frequently reported, most reports follow inhaled, smoked, or vaporised forms of cannabis, especially in chronic drug abusers [5]. Here, we report an unexpected event where the young man consumed Bhang as a recreational activity. This beverage is prepared using dried mature leaves of the Cannabis sativa plant, the Indian hemp plant, which grows in most parts of the world.

Delta-9-tetrahydrocannabinol (delta-9-THC, Fig. 4), the predominant form of THC in cannabis, possesses a dibenzopyran ring structure. The double bond at the 9th position in the pyran ring is essential for interaction with cannabinoid receptors (CB1 and CB2) widely distributed through the human body, including regions of the central and peripheral nervous systems, immune cells, and platelets. These are associated with the Gi protein, an inhibitory GTP-binding protein-coupled receptor. These are triggered by an agonist such as THC, inhibiting adenylyl cyclase (AC), decreasing intracellular cAMP levels, and ultimately facilitating platelet aggregation and activation.

Thrombosis occurs due to alterations in blood coagulability inside the coronary arteries, potentially resulting in myocardial infarction. Platelets, which facilitate coagulation, play a central role in this process. Cannabinoid receptors (CB1R and CB2) are expressed, which are activated by cannabis compounds (delta-9-THC), resulting in heightened platelet activation and aggregation, hence elevating the risk of thrombosis. Cannabis may induce inflammation in blood vessels, resulting in endothelial dysfunction and promoting platelet activation and thrombus formation. Moreover, cannabis consumption may cause vasoconstriction, so diminishing blood supply to the cardiac muscle and heightening the likelihood of a cardiac incident [6], [7].

On the other hand, alcohol exhibits a multifaceted association with cardiovascular health. Moderate alcohol intake exhibits anti-inflammatory properties and promotes cardiovascular health. Excessive alcohol consumption disrupts the body's standard coagulation mechanism, resulting in a hypercoagulable condition and enhancing the risk of thrombosis [8].

The simultaneous consumption of alcohol and cannabis exacerbates the associated risks. Individuals who concurrently use both typically exhibit elevated alcohol consumption, hence intensifying the corresponding hazards. Moderate alcohol consumption reduces platelet reactivity, whereas binge drinking elevates thromboxane levels, resulting in platelet hyperaggregation [9]. The synergistic effect of enhanced clotting potential from cannabis and alcohol can markedly elevate the risk of coronary thrombosis and subsequent cardiovascular incidents (Fig. 5).

Recreational use involves untitrated concentrations, and intoxication is known to impair processing speed, cognition, and psychomotor abilities when used in higher doses. There is no method of quality control of these products [10]. The biological properties of cannabis are related to cannabinoids that depend on their interactions with G protein-coupled cannabinoid receptors, CB1 and CB2. THC is a partial agonist of both CB1 and CB2 receptors but has a higher affinity for the CB1 receptor, which appears to mediate its psychoactive properties. The CB1 receptors are in the CNS, immune cells, gastrointestinal, reproductive, adrenal, heart, lung, and bladder tissues. The CB2 receptors are thought to have immunomodulatory effects and to regulate cytokine activity. THC has anti-inflammatory, anti-cancer, analgesic, muscle relaxant, and neuro-antioxidative properties. It has also been associated with anxiety, cholinergic deficits, and immunosuppression [11]. There is autonomic dysregulation with alteration in coronary microcirculation, which acts to cause deleterious clinical events rather than any sole mechanism [12]. In this case, the young man, despite lacking conventional cardiovascular risk factors, experienced acute myocardial injury, possibly due to a THC-induced thrombotic event and coronary vasospasm aggravated by concurrent alcohol consumption. [13]. One of the notable challenges in this scenario was the delayed recognition of symptoms due to misinterpretation. Cannabis intoxication can impair attention and information processing, especially in occasional users, leading to delayed medical attention when symptoms such as chest pain manifest. This delay emphasizes the importance of thorough history-taking regarding substance use, especially in young patients presenting with chest pain [14], [15], [16].

Since the above-discussed case involves a cannabis user consuming it at a festival, the reported symptoms and the perceived need for medical assistance were delayed for a significant duration.

Secondly, young AMI usually presents as a single-vessel disease [3]. The double-vessel coronary involvement with more extensive MI in a young man can be supported by recent literature that suggests that recreational drugs-induced MI has more severe presentations in <50-year-old patients. Therefore, this kind of AMI is a serious event that requires prompt diagnosis and management to prevent complications and mortality.

Furthermore, the evolving landscape of cannabis regulations necessitates heightened awareness among health authorities about potential cardiovascular risks associated with its consumption, particularly in forms like Bhang, where concentrations are unregulated and variable.