Validation of a brief observation period for patients with cocaine-associated chest pain

BACKGROUND

Retrospective studies of patients with cocaine-associated chest pain suggest that a strategy of discharging patients from the emergency department after a 12-hour observation period if they do not have evidence of ischemia should be associated with a very low rate of complications.

METHODS

We prospectively evaluated the safety of a 9-to-12-hour observation period in patients with cocaine-associated chest pain who were at low-to-intermediate risk of cardiovascular events. Consecutive patients who reported or tested positive for cocaine use and who received protocol-driven care in a chest-pain observation unit were included. Patients who had normal levels of troponin I, without new ischemic changes on electrocardiography, and who had no cardiovascular complications (dysrhythmias, acute myocardial infarction, or recurrent symptoms) during the 9-to-12-hour observation period were discharged from the unit. The main outcome was death from cardiovascular causes at 30 days.

RESULTS

Three hundred forty-four patients with cocaine-associated chest pain were evaluated. Forty-two of these patients (12 percent) were directly admitted to the hospital. The study cohort comprised the remaining 302 patients. During the 30-day follow-up period, none of the patients died of a cardiovascular event (0 percent; 95 percent confidence interval, 0 to 0.99), and only 4 of the 256 patients for whom detailed follow-up data were available had a nonfatal myocardial infarction (1.6 percent; 95 percent confidence interval, 0.1 to 3.1). All four nonfatal myocardial infarctions occurred in patients who continued to use cocaine.

CONCLUSIONS

Patients with cocaine-associated chest pain who do not have evidence of ischemia or cardiovascular complications over a 9-to-12-hour period in a chest-pain observation unit have a very low risk of death or myocardial infarction during the 30 days after discharge.

Impairment of myocardial protection in type 2 diabetic patients

Diabetic patients are more prone to develop postinfarction complications. It remained unclear whether diabetes mellitus- or sulfonylureas-associated changes of ATP-sensitive potassium (K(ATP)) channels, an integral player in ischemic preconditioning, are responsible for the increased mortality. The purpose of this study was to determine the impact of diabetes mellitus per se and different sulfonylurea administration on cardioprotective effects in diabetic patients undergoing coronary angioplasty. Myocardial ischemia after coronary angioplasty was evaluated in 20 nondiabetic and 23 diabetic patients chronically taking either glibenclamide or glimepiride. Nondiabetic patients treated with glimepiride significantly lowered the ischemic burden assessed by an ST-segment shift, chest pain score, and myocardial lactate extraction ratios compared with the glibenclamide-treated patients, implying that acute administration of glimepiride did not abolish cardioprotection. In the diabetic glibenclamide-treated group, the reduction in the ST-segment shift afforded by nicorandil in the first inflation (-58% vs. the first inflation in the glibenclamide group alone) was similar to that afforded by preconditioning (-59% during the second vs. the first inflation). In glimepiride-treated groups, the magnitude of attenuated lactate production was less in diabetes than that in nondiabetes at the second inflation, suggesting that diabetes mellitus per se plays a role in determining lactate production. Our results show that both diabetes mellitus and sulfonylureas can act in synergism to inhibit activation of K(ATP) channels in patients undergoing coronary angioplasty. The degree of inhibition assessed by metabolic and electrocardiographic parameters is less severe during treatment with glimepiride than with glibenclamide. Restitution of a preconditioning response in glimepiride-treated patients may be the potential beneficial mechanism.

Effect of continuous ATP injection on human hemodynamics

Continuous ATP injection is used clinically for Tl imaging or coronary flow measurement and because the effect on human hemodynamics is unknown, the present study investigated it in 14 patients undergoing heart catheter examination. Continuous ATP injection induced chest symptoms in 13 of the patients and second-degree atrioventricular block in one, but these complications disappeared immediately after the end of ATP infusion. Continuous ATP injection decreased aortic pressure, but increased pulmonary artery pressure, right atrial pressure and pulmonary capillary wedge pressure. ATP increased heart rate, stroke volume and cardiac output, the latter the result of an increase in preload, a decrease in afterload, and the increase in heart rate.

A case of coronary spasm induced by 5-fluorouracil

Cardiotoxicity is an uncommon adverse effect of 5-fluorouracil (5-FU). Coronary artery spasm has been postulated to be involved in the mechanism of this incident Patients may present with angina, myocardial infarction, arrhythmias and/or even sudden death. When the drug is readministered, there is a high risk of relapse. The underlying mechanisms of cardiotoxicity are not yet fully understood, although coronary vasospasm may be responsible. We report one woman receiving 5-fluorouracil therapy with typical chest pain and electrocardiographic changes consistent with acute coronary syndrome. A resolving pain and normalisation of ECG changes with nitrate therapy and normal coronary arteries indicate that this incident was about a coronary spasm caused by 5-FU.

Evidence against strong correlation between chest symptoms and ischemic coronary changes after subcutaneous sumatriptan injection

OBJECTIVE

To evaluate the adverse events possibly caused by sumatriptan injection and explore the relationship between chest symptoms along with sumatriptan injection and coronary ischemia among Japanese patients with migraine.

METHODS

A cumulative total of 112 subcutaneous injections in 62 patients were evaluated. ECG was continuously monitored before and until 5 minutes after injection on 92 occasions.

PATIENTS

Sixteen men and 46 women aged from 16 to 60 (mean 39+/-12) years. Their clinical diagnoses were migraine with aura, migraine without aura, cluster headache, and others.

RESULTS

Chest symptoms occurred following 17% of all injections and in 15% of all patients. None of these chest symptoms was accompanied by ECG changes.

CONCLUSIONS

Although the risk of coronary ischemia with sumatriptan treatment is commonly stated, our data suggest that chest symptoms following sumatriptan injection are not strongly associated with coronary ischemia in the Japanese population. The mechanism of chest symptoms following sumatriptan administration should be further elucidated.

Adverse reaction characterized by chest pain, shortness of breath, and syncope associated with verteporfin (visudyne)

PURPOSE

To report a serious adverse reaction associated with verteporfin infusion.

DESIGN

Observational case report.

METHODS

Case report of a single individual undergoing photodynamic therapy (PDT) with verteporfin.

RESULTS

A 77-year-old man with long-standing asymptomatic atrial fibrillation, but no known coronary artery disease experienced severe chest and neck pain, shortness of breath, and syncope while undergoing a fourth photodynamic therapy (PDT) treatment with verteporfin. This infusion had been preceded by three prior infusions; the first two were uneventful, and the third was associated with milder, but similar symptoms. Evaluation demonstrated that the chest pain was noncardiac in origin.

CONCLUSION

As verteporfin continues to be used around the world, physicians must be alert to the possibility of serious adverse side effects associated with its use.

Cocaine related chest pain: are we seeing the tip of an iceberg?

The recreational use of cocaine is on the increase. The emergency nurse ought to be familiar with some of the cardiovascular consequences of cocaine use. In particular, the tendency of cocaine to produce chest pain ought to be in the mind of the emergency nurse when faced with a young victim of chest pain who is otherwise at low risk. The mechanism of chest pain related to cocaine use is discussed and treatment dilemmas are discussed. Finally, moral issues relating to the testing of potential cocaine users will be addressed.

[Angina related to 5-Fluorouracil]

Treatment with 5-fluorouracil is common in oncological patients. Side effects on bone marrow, skin, and mucous membranes have been reported. Cardiotoxicity, which is less predictable, can be life-threatening. Manifestations include angina, arrhythmias, infarction, heart failure and cardiogenic shock. The toxic mechanisms that might be involved have been much discussed but have not yet been clearly established. Current evidence supports the possibility of a metabolic effect in common with the cascade secondary to ischemia due to coronary disease. Based on a case report, we discuss the usual clinical presentation, treatment and prognosis. Finally we make recommendations for managing patients being treated with 5-fluorouracil.

[Serratia marcescens vaccine in the treatment of malignant pleural effusion]

OBJECTIVE

To evaluate the efficacy and toxicity of Serratia marcescens (S311) vaccine in the treatment of malignant pleural effusion.

METHODS

Thirty-four patients with malignant pleural effusion were given S311 as intrapleural injection with a dose of 10(9) U (0.32 mg) on D 1, 8 and 15, and observed for four weeks.

RESULTS

The overall response rate (CR + PR) was 97.1% (CR in 12 patients and PR in 21 patients). The systemic toxicity was mild, including fever (82.4%), pleuritic pain (50.7%), nansea (26.5%), dyspnea (17.5%) and chills (5.9%).

CONCLUSION

Serratia marcescens vaccine is effective for malignant pleural effusion, with tolerable toxic effects. Further study is warranted.

Adverse reactions to dipyridamole in patients undergoing stress/rest cardiac perfusion testing

OBJECTIVE

A reaction scale was used to assess noncardiac adverse reactions exhibited by nuclear medicine outpatients receiving intravenous dipyridamole for pharmacological stress testing.

METHODS

The study included 933 patients referred to 2 cardiac outpatient centers for assessment. All patients evaluated in this study were unable to perform treadmill stress testing and underwent pharmacological intravenous dipyridamole stress testing. Dual-isotope (201)Tl rest/(99m)Tc-sestamibi stress imaging was performed. An analysis of adverse reactions exhibited by patients given dipyridamole was tabulated.

RESULTS

Of the 933 patients, 520 (55.7%) demonstrated no adverse reaction to intravenous dipyridamole; 413 patients (44.3%) had adverse reactions of some type. Many of these patients had multiple types of reactions, and a total of 604 reactions were recorded. The most prevalent adverse reaction was headache (224 reactions; 37.1%), followed by chest pain (73 reactions; 12.1%), and nausea (67 reactions; 11.1%). A sex comparison revealed 271 of 454 male patients (59.7%) and 249 of 479 female patients (52%) demonstrated no adverse reaction to intravenous dipyridamole. An evaluation of the most prevalent adverse reaction (headache) demonstrated a significant difference between males (37.9%) and females (62.1%).

CONCLUSION

An adverse reaction scale characterizing common noncardiac side effects of dipyridamole in nuclear medicine cardiac patients demonstrated the most prevalent adverse reaction was headache. Analysis by sex revealed that significantly more females than males complained of headaches.

Possible mesalamine-induced pericarditis: case report and literature review

Pericarditis should be considered in any patient complaining of chest pain and/or dyspnea who is taking a product that contains mesalamine or sulfasalazine. A 41-year-old woman was taking mesalamine 800 mg 3 times/day for 3 weeks before hospital admission. She complained of sharp, pleuritic chest pain that radiated down both arms and increased in intensity when lying down. She was diagnosed with pericarditis based on clinical presentation and electrocardiogram findings. Differential diagnoses for myocardial infarction, systemic lupus erythematosus, and viral or bacterial causes were ruled out based on subjective and objective data. Mesalamine-induced pericarditis was considered on hospital day 2, and the drug was discontinued at discharge on day 3. Clinicians should be aware of this potential drug-related complication, as the relationship between mesalamine or sulfasalazine and pericarditis has been reported rarely in the literature.

Almotriptan versus sumatriptan in migraine treatment: direct medical costs of managing adverse chest symptoms

OBJECTIVE

Triptans, a popular class of drugs for treatment of migraine headaches, can cause adverse events including chest symptoms. This study estimated the direct medical costs of managing chest symptoms in patients treated for acute migraine with almotriptan or sumatriptan using an economic model.

METHODS

The economic model of this study combined data from a randomized clinical trial that compared almotriptan with sumatriptan and data from a practice pattern survey of physicians. The pertinent clinical evaluation period was the time immediately after administration of the first medication dose. The model was developed from the perspective of a managed care payer.

RESULTS

The average direct medical cost of managing chest symptoms that appeared after the first dose of an oral triptan was $0.22 for patients treated with almotriptan and $1.64 for patients treated with sumatriptan, a difference of $1.42 per patient.

CONCLUSION

Relative to sumatriptan, treatment with almotriptan is likely to reduce patient care costs associated with chest symptom adverse events.

Cost savings in migraine associated with less chest pain on new triptan therapy

OBJECTIVES

This article constructs an economic model to estimate cost of chest-pain-related care in migraine patients receiving almotriptan 12.5 mg compared with those receiving sumatriptan 50 mg.

STUDY DESIGN

This population-based, retrospective cohort study used data from the MEDSTAT Marketscan database (Ann Arbor, Michigan) to quantify incidence and costs of chest-pain-related diagnoses and procedures. After a 6-month exclusion period, the study used a pre-post design, with baseline and treatment periods defined, respectively, as 5 months before and after receiving sumatriptan therapy. An economic model was constructed to estimate annual cost savings per 1,000 patients receiving almotriptan instead of sumatriptan as a function of differing rates of chest pain. Annual direct medical cost avoided was calculated for a hypothetical health plan covering 1 million lives.

RESULTS

Among a cohort of 1,390 patients, the incidence of chest-pain-related diagnoses increased significantly (43.6%) with sumatriptan, from 110 during the baseline period to 158 during the treatment period (P= .003). Aggregate costs for chest-pain-related diagnoses and procedures increased 33.1%, from $22,713 to $30,234. Payments for inpatient hospital services rose 10-fold; costs for primary care visits and outpatient hospital visits rose 53.1% and 14.4%, respectively. Payments for angiography increased from $0 to $462, and costs for chest radiographs and electrocardiograms increased 58.7% and 31.2%, respectively. Sumatriptan treatment was associated with a 3-fold increase in payments for services for painful respiration and other chest pain. The model predicted $11,215 in direct medical cost savings annually per 1000 patients treated with almotriptan instead of sumatriptan. Annual direct medical costs avoided for the health plan totaled $195,913.

CONCLUSION

Using almotriptan instead of sumatriptan will likely reduce the cost of chest-pain-related care for patients with migraine headaches.

Impact of chest pain on cost of migraine treatment with almotriptan and sumatriptan

Chest-related symptoms occur with all triptans; up to 41% of patients with migraine who receive sumatriptan experience chest symptoms, and 10% of patients discontinue treatment. Thus, the cost of chest pain-related care was estimated in migraineurs receiving almotriptan 12.5 mg versus sumatriptan 50 mg. A population-based, retrospective cohort study used data to quantify the incidence and costs of chest pain-related diagnoses and procedures. An economic model was constructed to estimate annual cost savings per 1000 patients receiving almotriptan versus sumatriptan based on the reported rates of chest pain. Annual direct medical cost avoided was calculated for a hypothetical health plan covering 1 million lives. Among a cohort of 1390 patients, the incidence of chest pain-related diagnoses increased significantly by 43.6% with sumatriptan (P=.003). Aggregate costs for chest pain-related diagnoses and procedures increased from $22,713 to $30,234. Payments for inpatient hospital services, costs for primary care visits, and costs for outpatient hospital visits increased by over 100%, 53.1%, and 14.4%, respectively. The model predicted $11,215 in direct medical cost savings annually per 1000 patients treated with almotriptan versus sumatriptan. Annual direct medical costs avoided totaled $194,358, and when applied to recent estimates of 86 million lives currently covered by almotriptan treatment, translates into an annual cost savings of just under $17 million for chest pain and associated care. Thus, using almotriptan in place of sumatriptan will likely reduce the cost of chest pain-related care.

5-fluorouracil-induced cardiotoxicity mimicking myocardial infarction: a case report

BACKGROUND

Severe cardiotoxicity is a documented, but very unusual side-effect of intravenous 5-fluorouracil therapy. The mechanism producing cardiotoxicity is poorly understood.

CASE PRESENTATION

A case of 5-fluorouracil-induced cardiotoxicity, possibly due to coronary artery spasm, and mimicking acute anterolateral myocardial infarction is presented and discussed. Electrocardiographs highlighting the severity of the presentation are included in the report along with coronary angiograms demonstrating the absence of significant coronary atherosclerosis.

CONCLUSION

Severe 5-fluorouracil-induced cardiotoxicity is rare, but can be severe and may mimic acute myocardial infarction, leading to diagnostic and therapeutic dilemmas. Readministration of 5-fluorouracil is not advised following an episode of cardiotoxicity.

A pilot study to assess the safety of dobutamine stress echocardiography in the emergency department evaluation of cocaine-associated chest pain

STUDY OBJECTIVE

Chest pain in the setting of cocaine use poses a diagnostic dilemma. Dobutamine stress echocardiography (DSE) is a widely available and sensitive test for evaluating cardiac ischemia. Because of the theoretical concern regarding administration of dobutamine in the setting of cocaine use, we conducted a pilot study to assess the safety of DSE in emergency department patients with cocaine-associated chest pain.

METHODS

A prospective case series was conducted in the intensive diagnostic and treatment unit in the ED of an urban tertiary-care teaching hospital. Patients were eligible for DSE if they had used cocaine within 24 hours preceding the onset of chest pain and had a normal ECG and tropinin I level. Patients exhibiting signs of continuing cocaine toxicity were excluded from the study. All patients were admitted to the hospital for serial testing after the DSE testing in the intensive diagnostic and treatment unit.

RESULTS

Twenty-four patients were enrolled. Two patients had inadequate resting images, one DSE was terminated because of inferior hypokinesis, another DSE was terminated because of a rate-related atrial conduction deficit, and 1 patient did not reach the target heart rate. Thus, 19 patients completed a DSE and reached their target heart rates. None of the patients experienced signs of exaggerated adrenergic response, which was defined as a systolic blood pressure of greater than 200 mm Hg or the occurrence of tachydysrhythmias (excluding sinus tachycardia). Further suggesting lack of exaggerated adrenergic response, 13 (65%) of 20 patients required supplemental atropine to reach their target heart rates.

CONCLUSION

No exaggerated adrenergic response was detected when dobutamine was administered to patients with cocaine-related chest pain.