COCAINE-ASSOCIATED
CHEST PAIN: HOW COMMON IS MYOCARDIAL INFARCTION?
Weber
JE, et al. Acad Emerg Med 2000 Aug;7(8):873-7
OBJECTIVE:
Prior studies addressing the incidence of acute myocardial infarction (AMI) in
patients with cocaine-associated chest pain have found divergent results.
Previous prospective studies, which found approximately a 6% incidence of AMI,
have been criticized for selection bias. This study sought to determine the
rate of AMI in patients with cocaine-associated chest pain.
METHODS:
All patients seen in an urban university-affiliated hospital between July 1996
and February 1998 were identified by ICD-9 medical records search for cocaine
use and chest pain/ acute coronary syndromes. In this system, all faculty admit
all patients with cocaine-associated chest pain for at least 23-hour
observation periods. Data collected included demographics, medical and cocaine
use history, presenting characteristics, hospital course, cardiovascular
complications, and diagnostic tests using a 119-item closed-question data
instrument with high interrater reliability. The main outcome measure was AMI
according to World Health Organization (WHO) criteria.
RESULTS:
There were 250 patients identified with a mean age of 33.5 +/- 8.5 years; 77%
were male; 84% were African American. Of 196 patients tested, 185 had cocaine
or cocaine metabolites in the urine (94%). The incidence of cardiac risk
factors were: hypercholesterolemia, 8%; diabetes, 6%; family history, 34%;
hypertension, 26%; tobacco use, 77%; prior MI, 6%; and prior chest pain, 40%.
Seventy-seven percent admitted to cocaine use in the preceding 24 hours: crack,
85%; IV, 2%; nasal, 6%. Twenty-five patients (10%) had electrocardiographic
evidence of ischemia. A total of 15 patients experienced an AMI (6%; 95% CI =
4.1% to 8.9%) using WHO criteria. Complications were infrequent:
bradydysrrhythmias, 0.4%; congestive heart failure, 0.4%; supraventricular
tachycardia, 1.2%; sustained ventricular tachycardia, 0.8%.
CONCLUSION:
The incidence of AMI was 6% in patients with cocaine-associated chest pain.
This result is identical to that found in prior prospective studies.
COCAINE-ASSOCIATED
CHEST PAIN: ONE-YEAR FOLLOW-UP.
Hollander
JE, et al. Acad Emerg Med 1995 Mar;2(3):179-84
OBJECTIVE:
To determine the one-year mortality and incidence of myocardial infarction (MI)
post-hospital discharge or ED release for patients with cocaine-associated
chest pain.
METHODS:
A prospective, observational study of an inception cohort of consecutive
patients who presented to one of four municipal hospital EDs with
cocaine-associated chest pain. Patients were followed for one year from the end
of the enrollment period. Main outcome parameters were the one-year actuarial
survival and the frequency of nonfatal MI.
RESULTS:
Mortality data were available for all 203 patients at a mean of 408 days.
Additional clinical information was available for 185 patients (91%). There
were six deaths (one-year actuarial survival 98%; 95% CI, 95-100%); none from
MI. Nonfatal MI occurred in two patients (1%; 95% CI, 0-2%). Continued cocaine
use was common (60%; 95% CI, 52-68%) and was associated with recurrent chest
pain (75% vs 31%, p < 0.0001). No MI or death was reported for patients who
claimed to have ceased cocaine use.
CONCLUSIONS:
Patients who presented with cocaine-associated chest pain commonly continued to
use cocaine after discharge. Urgent evaluation of coronary anatomy or cardiac
stress tests may not be necessary for patients for whom MI is ruled out and who
do not have recurrent potentially ischemic pain. The subsequent risk for MI and
death in this group appears to be low. Intervention strategies should emphasize
cessation of cocaine use.
PROSPECTIVE
MULTICENTER EVALUATION OF COCAINE-ASSOCIATED CHEST PAIN. COCAINE ASSOCIATED
CHEST PAIN (COCHPA) STUDY GROUP.
Hollander
JE, et al. Acad Emerg Med 1994 Jul-Aug;1(4):330-9
OBJECTIVE:
To describe a large cohort of patients who had chest pain following cocaine
use, and to determine the incidence of and clinical characteristics predictive
for myocardial infarction in this group of patients.
METHODS:
A prospective observational cohort study of consecutive patients with
cocaine-associated chest pain was conducted in six municipal hospital emergency
departments (EDs). Demographic variables, drug abuse patterns, medical
histories, chest pain characteristics, ECG results, and laboratory data were
recorded. Myocardial infarction was the primary endpoint.
RESULTS:
Fourteen of 246 patients (5.7%; 95% confidence interval [CI], 2.7-8.7%) had
myocardial infarction, as diagnosed by elevated CK-MB isoenzyme levels. There
were two deaths (0.8%). The patients had a median age of 33 years. The majority
were male (71.5%), non-white (83.3%), cigarette smokers (83.3%) who used
cocaine regularly. Chest pain began a median of 60 minutes after cocaine use
and persisted for a median of 120 minutes. Chest pain was most frequently
described as substernal (71.3%) and pressure-like (46.7%). Shortness of breath
(59.3%) and diaphoresis (38.6%) were common. There was no clinical difference
between patients who had myocardial infarctions and those who did not. Twelve
patients had arrhythmias and four had congestive heart failure. All cases
requiring intervention were evident upon presentation. An ECG revealing
ischemia or infarction had a sensitivity of 35.7% for predicting a myocardial
infarction. The specificity, positive predictive value, and negative predictive
value of the ECGs were 89.9%, 17.9%, and 95.8%, respectively.
CONCLUSIONS:
Myocardial infarction in patients who have cocaine-associated chest pain is not
uncommon. No clinical parameter available to the physician can adequately
identify patients at very low risk for myocardial infarction. Therefore, all
patients with cocaine-associated chest pain should be evaluated for myocardial
infarction.