Influence of intranasal cocaine on plasma constituents associated with endogenous thrombosis and thrombolysis

Cannabis and Other Substance Misuse: Implications and Regulations

Abusing controlled substances, including cannabis and various drugs, can result in severe intoxication and even death. Therefore, a comprehensive postmortem analysis is crucial for understanding the underlying causes of such fatalities. This narrative review discusses the characteristics of commonly abused controlled substances, the methodologies employed in postmortem analysis, lethal dosage levels, mechanisms of toxicity, side effects, and existing regulations. The focus centers on seven prevalent groups of controlled substances, namely cannabis, opioids, amphetamine-type stimulants, cocaine, new psychoactive substances, and hallucinogens. These groups have been linked to an increased risk of fatal overdose. Most substances in these groups exert neurotoxic effects by targeting the central nervous system (CNS). Consequently, strict regulation is essential to mitigate the potential harm posed by these substances. To combat abuse, prescribers must adhere to guidelines to ensure their prescribed medications comply with the outlined regulations. Through an enhanced understanding of controlled substance abuse and its consequences, more effective strategies can be developed to reduce its prevalence and associated mortality.

Early Onset Cardiovascular Disease from Cocaine, Amphetamines, Alcohol, and Marijuana

Cardiovascular disease (CVD), a disease typically associated with aging and the definitive leading cause of death worldwide, now threatens the young and middle-aged populations. Recreational abuse of alcohol, marijuana, cocaine and amphetamine-type stimulants has been an escalating public health problem for decades, but now use of these substances has become a significant contributor to early onset CVD. While this remains a global phenomenon, the epicenter of substance abuse is rooted in North America where it has been exacerbated by the COVID-19 pandemic. For the first time in history, the United States (US) crossed 100,000 overdose-related deaths in a calendar year. Sadly, Canada's recreational drug abuse problem closely mirrors that of the US. This is indicative of the larger public health crisis unfolding, as we now know that these substances are cardiotoxic and are contributing to the rising levels of premature chronic CVD, including hypertension, arrhythmias, heart failure, stroke, myocardial infarction, arterial dissection, sudden cardiac death and early mortality.

Acute Cardiovascular Toxicity of Cocaine

Cocaine is one of the most commonly abused drugs and represents a major public health concern. Cocaine users frequently present to the emergency department, with chest pain being the most common presenting complaint. The incidence of acute myocardial infarction in patients with cocaine-associated chest pain is often quoted as 6%, but it is highly variable depending on the included population. Risk assessment can be challenging in these patients; serial assessment of electrocardiograms and troponins is often required. This review focuses on the assessment and management of patients presenting with cocaine-associated chest pain and cardiotoxicity. Specific treatments are discussed, including benzodiazepines, nitroglycerin, calcium channel blockers, and phentolamine, and how treatment priorities differ from patients with noncocaine presentations. The use of beta-blockers in this population remains controversial, and the literature around its use is reviewed. The most recent literature and recommendations for the use of percutaneous coronary intervention and fibrinolytics in cocaine-associated myocardial infarction is discussed as well. Cocaine-associated dysrhythmias are suggested to be the cause of sudden cardiac death in some users. The pathophysiology and evidence-based treatments for dysrhythmias are reviewed. This review provides evidence-based recommendations for the assessment and management of patients presenting with cocaine-associated cardiovascular toxicity.

Cocaine-induced rhabdomyolysis and compartment syndrome

A man in his 30s with a history of cocaine and intranasal heroin use presented to the emergency department with severe leg pain and weakness. Physical examination findings were significant for tachycardia, absence of dorsalis pedis pulses, tense and painful calf muscles along with absence of plantar reflexes in bilateral lower extremities. Laboratory investigations were significant for positive urinary drug screen for cocaine, severe rhabdomyolysis and acute kidney injury. Given the absence of dorsalis pedis pulses in bilateral lower extremities and radiological evidence of oedematous changes in calf muscles with perimuscular oedema, a diagnosis of compartment syndrome was made. He was treated with bilateral lower extremity four-compartment fasciotomies and haemodialysis for acute kidney injury. Rhabdomyolysis has been attributed to cocaine use; however, compartment syndrome is a very rare complication, especially in the absence of trauma or prolonged immobilisation.

Cocaine: A Provoking Risk Factor in Venous Thromboembolism

Cocaine is a highly addictive recreational drug that is a well-known cause of a variety of disease processes such as stroke, myocardial infarction, and even sudden cardiac death. In current literature, venous thrombosis secondary to cocaine abuse remains under-examined, while the harmful effects of the drug within the arterial vasculature are well-studied and understood. Our case presents a patient who was found to have a large pulmonary embolism and pulmonary infarction after several days of cocaine abuse. This report serves to raise awareness of a potentially life-threatening effect of this drug and to encourage prompt diagnosis and treatment of cocaine-induced pulmonary embolism.

Post-ischaemic exuberant left ventricular mass: thrombus vs. tumour-case report

Background

We present a case that illustrates the diagnostic challenge of differentiating thrombus from tumour when confronted with a large left ventricular (LV) cardiac mass.

Case Summary

A 43-year-old Caucasian woman polysubstance-abuser presented to a regional hospital with an ST-elevation myocardial infarction and underwent aspiration-thrombectomy and successful circumflex artery bare metal stenting. She was noted to have an exuberant LV mass on transthoracic echocardiogram the following day and transferred to our care. Transthoracic echocardiogram, transoesophageal echocardiogram, and cardiac magnetic resonance imaging were performed in an attempt to characterize the mass with conflicting findings for either thrombus or tumour. The mass was surgically excised and final pathology indicated a fibrin-rich thrombus.

Discussion

The association of the mass with an infarcted area of the left ventricle supported the diagnosis of thrombus. However, due to the size and some imaging features a myxoma could not be completely ruled out. Atypical presentations of thrombus can be difficult to differentiate from cardiac tumours.

Importance of a Risk Stratification Strategy to Identify High-risk Patients Presenting With Cocaine-associated Acute Coronary Syndrome

OBJECTIVE

Current guidelines recommend treating patients with cocaine-associated chest pain, unstable angina, or myocardial infarction similarly to patients with traditional acute coronary syndrome (ACS). Risk stratifying these patients could potentially reduce unnecessary procedures and improve resource utilization.

METHODS

This is a retrospective cross-sectional analysis of 258 patients presenting with cocaine-associated ACS who underwent cardiac catheterization in a community teaching hospital between 2006 and 2015. The primary outcome was the prevalence of acute obstructive coronary artery disease (CAD) requiring percutaneous coronary intervention and coronary artery bypass grafting compared with that of patients with normal coronary or nonobstructive disease.

RESULTS

Of the studied population, 36% had obstructive CAD requiring intervention and 64% were found to have normal coronaries or nonobstructive disease. Significant risk factors for obstructive CAD were older age, history of CAD, diabetes mellitus, dyslipidemia, ST-segment-elevation myocardial infarction, and troponin elevation. A logistic model was developed based on these variables, applied to the studied population, and was found to have 93% sensitivity in predicting the likelihood of obstructive CAD.

CONCLUSIONS

Cardiac catheterization in patients presenting with cocaine-associated ACS may be overutilized. A predictive model based on clinical risk factors may help individualize patient care and reduce unnecessary invasive diagnostic interventions.

Cocaine-Associated Myocardial Infarction

Myocardial ischaemia and infarction has become a well-recognized sequelae of cocaine use. The possibility of recent cocaine use should be assessed in patients with potential myocardial ischaemia because the treatment of patients with myocardial ischaemia related to cocaine differs from that of patients with myocardial ischaemia unrelated to cocaine. Patients with cocaine-associated myocardial ischaemia should receive initial treatment with benzodiazepines to decrease central adrenergic stimulation. Aspirin should be used to reduce thrombus formation, and nitroglycerin to reverse coronary vasoconstriction. Patients with continued ischaemia can be treated with either low doses of phentolamine, or verapamil. If ischaemia continues after treatment with these agents mechanical reperfusion or thrombolytic therapy should be considered depending upon the clinical circumstances. Patients with myocardial ischaemia secondary to cocaine should not receive treatment with beta adrenergic antagonists as these agents enhance coronary vasoconstriction thereby worsening ischaemia.

The Cardiovascular Effects of Cocaine

Cocaine is the leading cause for drug-abuse-related visits to emergency departments, most of which are due to cardiovascular complaints. Through its diverse pathophysiological mechanisms, cocaine exerts various adverse effects on the cardiovascular system, many times with grave results. Described here are the varied cardiovascular effects of cocaine, areas of controversy, and therapeutic options.

Pathophysiological mechanisms of catecholamine and cocaine-mediated cardiotoxicity

Overactivation of the sympatho-adrenergic system is an essential mechanism providing short-term adaptation to the stressful conditions of critical illnesses. In the same way, the administration of exogenous catecholamines is mandatory to support the failing circulation in acutely ill patients. In contrast to these short-term benefits, prolonged adrenergic stress is detrimental to the cardiovascular system by initiating a series of adverse effects triggering significant cardiotoxicity, whose pathophysiological mechanisms are complex and only partially elucidated. In addition to the development of myocardial oxygen supply/demand imbalance induced by the sustained activation of adrenergic receptors, catecholamines can damage cardiomyocytes by fostering mitochondrial dysfunction, via two main mechanisms. The first one is calcium overload, consecutive to β-adrenergic receptor-mediated activation of protein kinase A and subsequent phosphorylation of multiple Ca(2+)-cycling proteins. The second one is oxidative stress, primarily related to the transformation of catecholamines into "aminochromes," which undergo redox cycling in mitochondria to generate copious amounts of oxygen-derived free radicals. In turn, calcium overload and oxidative stress promote mitochondrial permeability transition and cardiomyocyte cell death, both via the apoptotic and necrotic pathways. Comparable mechanisms of myocardial toxicity, including marked oxidative stress and mitochondrial dysfunction, have been reported with the use of cocaine, a common recreational drug with potent sympathomimetic activity. The aim of the current review is to present in detail the pathophysiological processes underlying the development of catecholamine and cocaine-induced cardiomyopathy, as such conditions may be frequently encountered in the clinical practice of cardiologists and ICU specialists.

Argon blocks the expression of locomotor sensitization to amphetamine through antagonism at the vesicular monoamine transporter-2 and mu-opioid receptor in the nucleus accumbens

We investigated the effects of the noble gas argon on the expression of locomotor sensitization to amphetamine and amphetamine-induced changes in dopamine release and mu-opioid neurotransmission in the nucleus accumbens. We found (1) argon blocked the increase in carrier-mediated dopamine release induced by amphetamine in brain slices, but, in contrast, potentiated the decrease in KCl-evoked dopamine release induced by amphetamine, thereby suggesting that argon inhibited the vesicular monoamine transporter-2; (2) argon blocked the expression of locomotor and mu-opioid neurotransmission sensitization induced by repeated amphetamine administration in a short-term model of sensitization in rats; (3) argon decreased the maximal number of binding sites and increased the dissociation constant of mu-receptors in membrane preparations, thereby indicating that argon is a mu-receptor antagonist; (4) argon blocked the expression of locomotor sensitization and context-dependent locomotor activity induced by repeated administration of amphetamine in a long-term model of sensitization. Taken together, these data indicate that argon could be of potential interest for treating drug addiction and dependence.

Controversial therapeutics: the β-adrenergic antagonist and cocaine-associated cardiovascular complications dilemma

Cocaine abuse is associated with cardiovascular complications that include chest pain and myocardial infarction. Traditional therapy for these conditions includes a β-adrenergic antagonist. However, guidelines released in 2008 recommended against this treatment option because of the prevailing theory that cocaine will potentiate vasospasm secondary to unopposed α-adrenergic effects. Subsequently, further evidence and updated guidelines have become available, debunking this claim. Current literature is limited but suggests that β-adrenergic antagonists are harmful. Although case reports support a detrimental effect of β-adrenergic antagonists, the anecdotal data are inconsistent, and the conclusions from case studies are overruled by larger studies. The pharmacology, pathophysiology, and literature on the use of β-adrenergic antagonists in association with cocaine are reviewed. Future studies that focus on outcomes and different pharmacologic profiles of β-adrenergic antagonists are needed.

Effect of serotonin on platelet function in cocaine exposed blood

5-hydroxytryptamine (5-HT) reuptake inhibitors counteract the pro-thrombotic effect of elevated plasma 5-HT by down-regulating the 5-HT uptake rates of platelets. Cocaine also down-regulates the platelet 5-HT uptake rates but in contrast, the platelets of cocaine-injected mice show a much higher aggregation rate than the platelets of control mice. To examine the involvement of plasma 5-HT in cocaine-mediated platelet aggregation, we studied the function of platelets isolated from wild-type and transgenic, peripheral 5-HT knock-out (TPH1-KO) mice, and cocaine-insensitive dopamine transporter knock in (DAT-KI) mice. In cocaine-injected mice compared to the control mice, the plasma 5-HT level as well as the surface level of P-selectin was elevated; in vitro platelet aggregation in the presence of type I fibrillar collagen was enhanced. However, cocaine injection lowered the 5-HT uptake rates of platelets and increased the plasma 5-HT levels of the DAT-KI mice but did not change their platelets aggregation rates further which are already hyper-reactive. Furthermore, the in vitro studies supporting these in vivo findings suggest that cocaine mimics the effect of elevated plasma 5-HT level on platelets and in 5-HT receptor- and transporter-dependent pathways in a two-step process propagates platelet aggregation by an additive effect of 5-HT and nonserotonergic catecholamine.

Cocaine use disorders and acute myocardial infarction, excess length of hospital stay and overexpenditure

INTRODUCTION AND OBJECTIVES

To investigate the relationship between the prevalence of cocaine use disorders and acute myocardial infarction in patients aged ≥ 18 years and to estimate the influence of cocaine use disorders on mortality, excess length of stay, and overexpenditure among hospitalized patients with acute myocardial infarction.

METHODS

Retrospective study of the minimum basic data set of 87 Spanish hospitals from 2008 to 2010.

RESULTS

Among 5 575 325 admissions reviewed, there were 24 126 patients with cocaine use disorders and 79 076 cases of acute myocardial infarction. The incidence of acute myocardial infarction among patients with cocaine use disorders increased with age and reached a peak at 55 years to 64 years (P < .0001). Multivariate analysis showed that cocaine use disorders were more prevalent among patients with acute myocardial infarction independently of age, sex, other addictive disorders, and 30 other comorbidities (odds ratio = 3.0). Among patients with acute myocardial infarction, those with cocaine use disorders did not show an increase of in-hospital death, but did show excess length of hospital stay (1.5 days) and overexpenditure (382 euros).

CONCLUSIONS

Cocaine use disorders are associated with acute myocardial infarction and increase the length of hospital stay and overexpenditure among acute myocardial infarction patients. Cessation of cocaine use among these patients should be one of the primary therapeutic goals after hospital discharge.

Comparison of in-hospital outcomes for beta-blocker use versus non-beta blocker use in patients presenting with cocaine-associated chest pain

Beta blockers are indicated for management of acute coronary syndromes, but they generally are withheld in patients with cocaine-associated chest pain because of concerns for adverse outcomes related to the unique physiological effects of cocaine. Because few clinical studies have evaluated this interaction, we identified patients with toxicology screen results positive for cocaine treated for chest pain at 2 academic hospitals. Clinical characteristics and in-hospital outcomes were compared between patients with and without β-blocker therapy. We then constructed propensity scores to evaluate the independent relation between β-blocker use and the composite primary end point of myocardial infarction, stroke, ventricular arrhythmia, or all-cause mortality after adjusting for clinical characteristics. Of 376 consecutive patients with cocaine-related chest pain, β blockers were used in 164 (44%). Compared with no β blockers, patients treated with β blockers were more likely to describe anginal chest pain, to have known cardiovascular risk factors, and to receive other antiatherosclerotic therapies. Despite these higher risk clinical characteristics, patients treated with β blockers experienced similar peak troponin levels, individual adverse events, and rates of the composite primary end point (15.9% vs 12.3%, p = 0.32). The primary end point also was similar after propensity score analysis (odds ratio 1.37, 95% confidence interval 0.64 to 2.93, p = 0.42), including specific comparisons of beta-1 selective (odds ratio 1.83, 95% confidence interval 0.79 to 4.24) and nonselective (odds ratio 0.90, 95% confidence interval 0.33 to 2.42) β blockers, when compared with patients not receiving β blockers. In conclusion, no differences in outcomes were observed between patients treated versus not treated with β-blocker therapy in the setting of cocaine-related chest pain.

Acute cocaine-related health problems in patients presenting to an urban emergency department in Switzerland: a case series

BACKGROUND

Emergency departments may be a useful information source to describe the demographics and clinical characteristics of patients with acute cocaine-related medical problems. We therefore conducted a retrospective analysis of 165 acute, laboratory-confirmed cocaine intoxications admitted to an urban emergency department in Switzerland between January 2007 and March 2011.

RESULTS

A total of 165 patients with a mean age of 32 years were included. Most patients were male (73%) and unemployed (65%). Only a minority (16%) had abused cocaine alone while 84% of the patients had used at least one additional substance, most commonly ethanol (41%), opioids (38%), or cannabis (36%) as confirmed by their detection in blood samples. The most frequently reported symptoms were chest pain (21%), palpitations (19%), anxiety (36%) and restlessness (36%). Psychiatric symptoms were present in 64%. Hypertension and tachycardia were observed in 53% and 44% of the patients, respectively. Severe poisonings only occurred in patients with multiple substance intoxication (15%). Severe intoxications were non-significantly more frequent with injected drug use compared to nasal, oral, or inhalational drug use. Severe complications included acute myocardial infarction (2 cases), stroke (one case), and seizures (3 cases). Most patients (75%) were discharged home within 24 h after admission. A psychiatric evaluation in the ED was performed in 24% of the patients and 19% were referred to a psychiatric clinic.

CONCLUSIONS

Patients with acute cocaine intoxication often used cocaine together with ethanol and opioids and presented with sympathomimetic toxicity and/or psychiatric disorders. Severe acute toxicity was more frequent with multiple substance use. Toxicity was typically short-lasting but psychiatric evaluation and referral was often needed.

Drug and alcohol use complicate traumatic peripheral vascular injury

BACKGROUND

Drug and alcohol use complicate the presentation and management of traumatic injuries. Impaired hemodynamic recovery and host defense in substance users also predispose these patients to worse outcomes after trauma. We hypothesized that substance abuse, particularly when drugs and alcohol are combined, complicates the presentation, management, and patient outcomes following isolated traumatic peripheral vascular injury.

METHODS

This is a retrospective analysis of patients admitted with isolated peripheral vascular injury to our Level 1 trauma center between 2006 and 2012. Demographics, presentation, substance use, resuscitation, operative management, intensive care needs, and length of hospital stay were analyzed.

RESULTS

From 257 patients admitted, 158 patients experienced isolated peripheral vascular injury. Patients were subdivided by blood alcohol level (BAL) and urinary toxicology (utox) screens; negative BAL/negative utox (nonintoxicated, n = 90), negative BAL/positive utox (drug users, n = 27), positive BAL/negative utox (alcohol users, n = 22), and positive BAL/positive utox (polysubstance users, n = 19). Compared with nonintoxicated patients, more polysubstance users experienced lower-extremity injury (79% vs. 47%) and presented more often than alcohol users with proximal injury (83% vs. 45%), lower-extremity injury (79% vs. 36%), and as a result of assault (68.4% vs. 31.8%). Polysubstance users required greater resuscitation, more operations, and more frequently experienced complications than any other cohort. Subsequently, these patients had a greater need for intensive care management and longer hospital stay than nonintoxicated and alcohol users. Moreover, using multivariate logistic regression analysis, we found that polysubstance use, alcohol use, and lower-extremity injury are each independent risk factors for infectious complications.

CONCLUSION

Our data show that polysubstance users with isolated peripheral vascular injury experience more proximal and lower-extremity injuries, require greater resuscitation, and undergo more operations compared with nonintoxicated patients. Treatment of these patients is more frequently complicated by infection, vascular complications, and increased hospital length of stay.

How to spot cocaine-induced pseudovasculitis

The prevalence of cocaine-induced pseudovasculitis (CIP) causing cutaneous destruction is increasing, and plastic surgeons need to be aware of this condition because they are a part of the multidisciplinary treatment team. Differentiation of CIP from a true autoimmune vasculitis can be exceedingly challenging, and misdiagnosis with ensuing treatment may be fatal. This article is a succinct review of CIP, guided by a clinical case of 30% total body surface area skin necrosis, to familiarize the reader with this syndrome. Diagnostic aids include history of cocaine use, localized disease manifestation to skin or mucosa, discordance of antineutrophil cytoplasmic antibody and target antibody patterns typical for true vasculitis, and testing for antihuman neutrophil elastase and levamisole. Treatment is primarily supportive, and wound care, with regard to dressings and surgery, is a cross between to that of burns and meningococcemia patients.

High mortality of cocaine-related ischemic colitis: a hybrid cohort/case-control study

BACKGROUND

Isolated case reports describe bowel ischemia in cocaine users, and the optimal management of these patients remains uncertain.

DESIGN

Case-control study.

SETTING

Teaching hospitals.

PATIENTS

Patients hospitalized for colonic ischemia related to cocaine compared with noncocaine-related ischemic colitis. Cases were identified by using ICD-9 codes and laboratory urine toxicology tests. Patients were included if they had a confirmed diagnosis of bowel ischemia by CT, colonoscopy, angiography, or, in the case of emergency exploration, a pathology report showing bowel ischemia and a urine toxicology test that was positive for cocaine. Controls were individuals who met the same criteria but had no history of cocaine use and a urine test negative for cocaine. Charts were individually audited for accuracy of coding.

MAIN OUTCOME MEASUREMENTS

Mortality and its risk factors.

RESULTS

Patients with cocaine-related ischemia were significantly younger and had a significantly (P < .05) higher mortality rate than patients with ischemic colitis unrelated to cocaine (cocaine: 5/19 [26%] and noncocaine: 6/78 [7.7%]). The cause of death in all cases was septic shock caused by extensive bowel ischemia. Multivariate logistic regression analysis showed that cocaine-related ischemic colitis was a significant risk factor for mortality (odds ratio 5.77; 95% CI, 1.37-24.39) as was the need for surgical intervention (odds ratio 4.95; 95% CI, 1.22-20.12).

LIMITATIONS

Retrospective design.

CONCLUSIONS

Cocaine-related ischemic colitis has a high mortality. In young patients presenting with acute abdominal pain and/or rectal bleeding with evidence of bowel wall thickening or pneumatosis on imaging studies or colonoscopy, cocaine-related ischemia should be considered. Testing for cocaine use may help identify patients at high risk of sepsis and death.

Relationship between cocaine use and coronary artery disease in patients with symptoms consistent with an acute coronary syndrome

OBJECTIVES

Observational studies of patients with cocaine-associated myocardial infarction have suggested more coronary disease than expected on the basis of patient age. The study objective was to determine whether cocaine use is associated with coronary disease in low- to intermediate-risk emergency department (ED) patients with potential acute coronary syndrome (ACS).

METHODS

The authors conducted a cross-sectional study of low- to intermediate-risk patients<60 years of age who received coronary computerized tomographic angiography (CTA) for evaluation of coronary artery disease (CAD) in the ED. Patients were classified into three groups with respect to CAD: maximal stenosis <25%, 25% to 49%, and ≥50%. Prespecified multivariate modeling (generalized estimating equations) was used to assess relationship between cocaine and CAD.

RESULTS

Of 912 enrolled patients, 157 (17%) used cocaine. A total of 231 patients had CAD ≥25%; 111 had CAD ≥50%. In univariate analysis, cocaine use was not associated with a lesion 25% or greater (12% vs. 14%; relative risk [RR]=0.89, 95% confidence interval [CI]=0.5 to 1.4) or 50% or greater (12% vs. 11%; RR=1.15, 95% CI=0.6 to 2.3). In multivariate modeling adjusting for age, race, sex, cardiac risk factors, and Thrombosis in Myocardial Infarction (TIMI) score, cocaine use was not associated with the presence of any coronary lesion (adjusted RR=0.95, 95% CI=0.69 to 1.31) or coronary lesions 50% or greater (adjusted RR=0.78, 95% CI=0.45 to 1.38). There was also no relationship between repetitive cocaine use and coronary calcifications or between recent cocaine use and CAD.

CONCLUSIONS

In symptomatic ED patients at low to intermediate risk of an ACS, cocaine use was not associated with an increased likelihood of coronary disease after adjustment for age, race, sex, and other risk factors for coronary disease.

Prevalence, clinical characteristics and risk of myocardial infarction in patients with cocaine-related chest pain

INTRODUCTION AND OBJECTIVES

To investigate the frequency of recent cocaine use in patients attending an emergency department for acute chest pain, to describe the clinical characteristics of these patients, and to estimate the incidence of acute coronary syndrome in this population.

METHODS

Observational cohort study using a standard questionnaire that includes items on recent cocaine consumption.

RESULTS

During a 1-year period, 1240 patients aged under 55 years presented with chest pain. Of these, 63 (5%) had cocaine-related chest pain (7% of men and 1.8% of women). These patients were younger (35+/-10 years vs. 39+/-10 years; P=.002), were more frequently male (87% vs. 62%; P< .001), and were more frequently smokers (59% vs. 35%; P< .001). Patients who had used cocaine recently had a higher incidence of acute myocardial infarction (16 vs. 4%; P< .001), especially ST-segment-elevation myocardial infarction (11.1% vs. 1.6%; P< .01). After adjusting for coronary risk factors, history of cardiovascular disease and previous treatment, the odds ratio for myocardial infarction with recent cocaine consumption was 4.3 (95% confidence interval, 2-9.4).

CONCLUSIONS

Cocaine-related chest pain is often encountered in emergency departments, especially in men aged under 55 years. It is associated with a four-fold increase in the risk of acute myocardial infarction. All male patients aged under 55 years with acute chest pain should be asked about cocaine use.

Cocaine and beta-blockers: the paradigm

Cocaine is one of the most commonly used substances of abuse. The use of beta-blockers in cocaine induced acute coronary syndrome has long been a matter of debate. While it is widely believed that beta-blockers are contraindicated in cocaine toxicity, there appears to be some recognizable role for certain beta-blockers in ameliorating the cardiovascular as well as central nervous system effects of cocaine. This article explores the role of beta-blockers in the management of cocaine toxicity.

Cocaine-related sudden death: a prospective investigation in south-west Spain

AIMS

With an estimated 12 million consumers in Europe, cocaine (COC) is the illicit drug leading to the most emergency department visits. The aim of this study was to examine a consecutive series of sudden deaths (SDs) to focus on the prevalence, the toxicological characteristics, and the causes of death in COC-related fatalities.

METHODS AND RESULTS

Prospective case-control study of forensic autopsies was carried out in the time interval November 2003 to June 2006 at the Institute of Legal Medicine, Seville, south-west Spain, with a reference population of 1 875 462 inhabitants. Toxicology included blood ethanol analysis and blood and urine investigation for drugs of abuse and medical drugs. Autopsy was performed according to the European standardized protocol. Ten age- and sex-matched patients who died of violent causes with no antecedents of COC consumption and negative toxicology served as controls. During the study period, 2477 forensic autopsies were performed, including 1114 natural deaths. Among the latter, 668 fulfilled the criteria of SD and 21 (all males, mean age 34.6 +/- 7.3 years) resulted to be COC-related (3.1%). Cocaine was detected in 67.1% of the blood (median 0.17 mg/L, interquartile range 0.08-0.42) and in 83.0% of the urine samples (median 1.15 mg/L, interquartile range 0.37-17.34). A concomitant use of ethanol was found in 76.0% and cigarette smoking in 81.0%. Causes of SD were cardiovascular in 62.0%, cerebrovascular in 14.0%, excited delirium in 14.0%, respiratory and metabolic in 5.0% each. Left ventricular hypertrophy was observed in 57.0%, small vessels disease in 42.9%, severe atherosclerotic coronary artery disease in 28.6%, and coronary thrombosis in 14.3%.

CONCLUSION

Systematic toxicology investigation indicates that 3.1% of SDs are COC-related and are mainly due to cardio-cerebrovascular causes. Left ventricular hypertrophy, small vessel disease, and premature coronary artery atherosclerosis, with or without lumen thrombosis, are frequent findings that may account for myocardial ischaemia at risk of cardiac arrest in COC addicts.

Clinical cases in acute intoxication

Over 2.5 million accidental and intentional drug-related poisonings are reported annually in the United States. Early diagnosis and management of patients who present with acute intoxication can significantly reduce both morbidity and mortality. The initial evaluation of patients with suspected or proven intoxications should focus on hemodynamic stability, mental status, and respiratory function. However, early recognition of toxic ingestion is paramount to implementing life-saving treatments. Important historical clues are often found in a social history that considers intravenous drug use, alcohol use, and any access or exposure to illicit substances. A patient's medication list should also be scrutinized for psychoactive or sedative medications, such as tricyclic antidepressants or opioids. In this article we present case-based discussions of the specific diagnosis and management of 5 commonly occurring acute intoxication syndromes.

Coronary computerized tomography angiography for rapid discharge of low-risk patients with cocaine-associated chest pain

BACKGROUND

Most patients presenting to emergency departments (EDs) with cocaine-associated chest pain are admitted for at least 12 hours and receive a "rule out acute coronary syndrome" protocol, often with noninvasive testing prior to discharge. In patients without cocaine use, coronary computerized tomography angiography (CTA) has been shown to be useful for identifying a group of patients at low risk for cardiac events who can be safely discharged. It is unclear whether a coronary CTA strategy would be efficacious in cocaine-associated chest pain, as coronary vasospasm may account for some of the ischemia. We studied whether a negative coronary CTA in patients with cocaine-associated chest pain could identify a subset safe for discharge.

METHODS

We prospectively evaluated the safety of coronary CTA for low-risk patients who presented to the ED with cocaineassociated chest pain (self-reported or positive urine test). Consecutive patients received either immediate coronary CTA in the ED (without serial markers) or underwent coronary CTA after a brief observation period with serial cardiac marker measurements. Patients with negative coronary CTA (maximal stenosis less than 50%) were discharged. The main outcome was 30-day cardiovascular death or myocardial infarction.

RESULTS

A total of 59 patients with cocaine-associated chest pain were evaluated. Patients had a mean age of 45.6 +/- 6.6 yrs and were 86% black, 66% male. Seventy-nine percent had a normal or nonspecific ECG and 85% had a TIMI score <2. Twenty patients received coronary CTA immediately in the ED, 18 of whom were discharged following CTA (90%). Thirty-nine received coronary CTA after a brief observation period, with 37 discharged home following CTA (95%). Six patients had coronary stenosis >or=50%. During the 30-day follow-up period, no patients died of a cardiovascular event (0%; 95% CI, 0-6.1%) and no patient sustained a nonfatal myocardial infarction (0%; 95% CI, 0-6.1%).

CONCLUSIONS

Although cocaine-associated myocardial ischemia can result from coronary vasoconstriction, patients with cocaine associated chest pain, a non-ischemic ECG, and a TIMI risk score <2 may be safely discharged from the ED after a negative coronary CTA with a low risk of 30-day adverse events.

Cocaine-related vasculitis causing scrotal gangrene

OBJECTIVE

To describe a case of possible cocaine-related vasculitis resulting in gangrene of the scrotum and review the literature on cocaine-related vascular complications.

CASE SUMMARY

A 22-year-old male presented with fever, painful swelling of the right scrotum, and a blackened ulcerated lesion on the right scrotum 3 hours after smoking crack cocaine. Blood and urine cultures and serologic tests were negative, and the D-dimer level was normal. Echocardiogram showed no evidence of vegetation and results of a chest X-ray were normal. Despite treatment for presumptive orchitis with intravenous levofloxacin 750 mg/day, the ulcerated lesion of the right scrotum progressed the next day. The patient received debridement of the necrotic tissue and pathology revealed some degenerated vessels with fibrinoid deposits and inflammatory infiltrates, suggestive of vasculitis. No further tenderness and swelling of the scrotum occurred and the patient was discharged after 10 days. When he returned for follow-up, the wound had healed completely.

DISCUSSIONS

Cocaine-related vascular complications, including ischemic stroke, myocardial infarction, and peripheral occlusive disease, all of which have various possible mechanisms, are of clinical importance. Vasculitis is one of the mechanisms of vascular complications associated with cocaine use. According to the Naranjo probability scale, cocaine was the possible causative agent of the patient's vasculitis, which led to scrotum gangrene. To our knowledge, this is the first report in the literature of scrotum gangrene developing after crack cocaine was smoked.

CONCLUSIONS

This case report describes a rare occurrence of gangrene of the scrotum associated with cocaine smoking, which is consistent with cocaine's potent vasoconstrictive activity. Cocaine abuse has the potential to cause clinically significant ischemic events anywhere in the body, independent of the method of administration.

Longitudinal Substance Use following an Emergency Department Visit for Cocaine-Associated Chest Pain

Substance abuse is a chronic, relapsing condition, yet some individuals over time seem to cease use for factors that are largely unclear. A life threatening episode of cocaine-associated chest pain requiring an emergency department (ED) visit may influence subsequent use. A consecutive cohort (n = 219) of patients who presented to a large, urban ED with cocaine-associated chest pain was interviewed at baseline, three months, six months, and 12 months to evaluate longitudinal rates of subsequent drug use. Overall, there was a significant decrease in cocaine use over time (baseline = 100.0%, three months = 56.5%, six months = 54.2%, and 12 months = 51.7%, p < .05 for baseline versus each follow-up interval). Findings suggest that substance use declines following an ED visit for cocaine-related chest pain. However, about half of the subjects were still using cocaine one year later. Future studies examining the potential impact of brief interventions or case management to intervene with this not-in-treatment ED population are warranted.

Acute stent thrombosis in the setting of cocaine abuse following percutaneous coronary intervention

The treatment of acute coronary syndrome (ACS) in patients with documented cocaine abuse has always presented significant challenges. Issues related to medication compliance, the potential risks of beta adrenergic blockade, and possible continued cocaine abuse postmyocardial infarction necessitate a unique, individualized approach to these patients. Recent data in the era of extensive percutaneous coronary interventions (PCI) and intracoronary stent (ICS) implantation have raised questions regarding the safety of ICS in patients who may revert to cocaine abuse postacute coronary syndrome as a result of the potentially higher risk of stent thrombosis in these patients. While the precise reason as to why cocaine use may increase the risk of stent thrombosis is not fully understood, it is likely the result of a confluence of factors, including coronary vessel vasoconstriction, impaired vascular compliance, as well as the platelet-activating effect of cocaine. We present the case a 46-year-old male with a history of cocaine abuse who presented with an acute stent thrombosis 2 days post-PCI likely as a result of cocaine abuse on the day of discharge following initial stent implantation for a non-ST-elevation myocardial infarction (NSTEMI). We also review the literature regarding the safety of PCI in cocaine abusers.

Thrombotic microangiopathy in cocaine abuse-associated malignant hypertension: report of 2 cases with review of the literature

Cocaine is one of the most commonly used illicit drugs. Acute renal failure is an emergent complication in patients with acute cocaine intoxication. It is well known that rhabdomyolysis and vasoconstriction can be important pathogenetic mechanisms resulting in acute renal failure in these patients. Clinically, although cocaine abuse is associated with elevated blood pressure, persistent accelerated hypertension reaching levels diagnostic of malignant hypertension is uncommon. Cocaine-induced malignant hypertension associated with morphologic features of thrombotic macroangiopathy has been rarely mentioned in the literature. We report 2 cases of cocaine abuse-associated malignant hypertension with renal failure. Kidney biopsies revealed thrombotic microangiopathy with fibrinoid necrosis of arterioles and glomerular tufts. Cocaine-mediated endothelial injury and platelet activation may play important pathogenetic roles in cocaine abusers who develop acute renal failure and malignant hypertension.

Cocaine and thrombosis: a narrative systematic review of clinical and in-vivo studies

Purpose

To systematically review the literature pertaining to the link between cocaine and either arterial or venous thrombosis.

Procedures

Narrative systematic review of Medline, CINAHL, Embase, Psycinfo and Cochrane databases supplemented by hand trawling of relevant journals and reference lists up to April 2007. In-vivo studies and those with clinical endpoints were included in the review.

Results

A total of 2458 abstracts led to 186 full-text papers being retrieved. 15 met the criteria for inclusion in the review. The weight of evidence would support cocaine as a pro-thrombotic agent. There is evidence of it activating thrombotic pathways. The effect of cocaine upon clinical endpoints has not been quantified though there is evidence of an association between cocaine and myocardial infarction particularly amongst young adults. Cocaine may also be a causal agent in cerebrovascular accident though studies lacked sufficient power to determine a statistically significant effect. There is a gap in the evidence pertaining to the issue of cocaine and venous thrombosis.

Conclusion

Clinicians should consider questioning for cocaine use particularly amongst young adults who present with cardiac symptoms. More epidemiological work is required to quantify the effect of cocaine upon both arterial and venous clotting mechanisms.

Crack whips the heart: a review of the cardiovascular toxicity of cocaine

Cocaine is an extremely powerful reinforcing psychostimulant with highly addictive properties. Over the last few decades, cocaine addiction has attained epidemic proportions in North America, imposing a tremendous burden on society and the health care system. The cardiovascular complications of cocaine abuse are adrenergic mediated and range from cocaine-associated acute coronary syndromes to aortic dissection and sudden cardiac death. Concomitant alcohol and cigarette smoking exacerbate the cardiotoxicity of cocaine. This contemporary review discusses the spectrum of cardiac complications arising from cocaine use, operant pathophysiologic mechanisms and controversies surrounding the pharmacotherapy of cocaine-associated acute coronary syndromes.

Four-Extremity Gangrene Associated With Crack Cocaine Abuse

A 43-year-old woman with a history of cocaine abuse presented with decreased mental responsiveness and cyanosis of the extremities several hours after repeated use of "crack" cocaine. She developed bilateral hand compartment syndrome requiring emergency fasciotomy and gangrene of both hands and legs despite anticoagulant and antithrombotic therapy. Digital and above-knee amputations were performed. There was no evidence of an autoimmune disorder or vasculitis on laboratory evaluation and tissue histology. Peripheral vasospasm may have been the mechanism of toxicity in this case, and the use of intravenous vasodilators should be considered as potential additional therapy.

Increased TIMI frame counts in cocaine users: a case for increased microvascular resistance in the absence of epicardial coronary disease or spasm

BACKGROUND

Cocaine produces adverse cardiovascular effects, some of which cannot be explained by epicardial coronary artery disease (CAD) or spasm.

HYPOTHESIS

The hypothesis of this study was that cocaine users would have increased coronary microvascular resistance, even in the absence of recent myocardial infarction (MI), CAD, or spasm.

METHODS

Microvascular resistance was assessed by the corrected Thrombolysis in Myocardial Infarction (TIMI) frame count (cTFC) method in a consecutive series of 59 cocaine users without acute or recent MI or angiographically significant epicardial stenosis (> 50%) or spasm. The cTFCs in these patients were compared with 21 normal controls and with published normal cTFC values.

RESULTS

The cTFC was significantly elevated (by 26-54%) in cocaine users. The cTFCs in the left anterior descending (LAD), circumflex (LCx), and right coronary (RCA)arteries in cocaine users were 30.0 +/- 10.9,34.1 +/- 11.5, and 28.6 +/- 11.8, respectively, compared with values in normal controls of 21.3 +/- 4.3 (p = 0.001), 24.4 +/- 7.2 (p = 0.001), and 22.7 +/- 5.1 (p = 0.04), respectively, and published normal cTFC values (all p < 0.01). An abnormally high cTFC was present in 61% of patients in the LAD, 69% in the LCx, and 47% in the RCA.

CONCLUSIONS

Markedly decreased coronary blood flow velocity, indicating increased microvascular resistance, is present in cocaine users, even in the absence of acute or recent MI, or significant epicardial CAD or spasm. Increased microvascular resistance may explain many important cardiovascular manifestations of cocaine use and has therapeutic implications. Slow coronary filling may also suggest the possibility of cocaine use in patients in whom it was not otherwise suspected.

Silencing urokinase in the ventral tegmental area in vivo induces changes in cocaine-induced hyperlocomotion

Serine proteases in the nervous system have functional roles in neural plasticity. Among them, urokinase-type plasminogen activator (uPA) exerts a variety of functions during development, and is involved in learning and memory. Furthermore, psychostimulants strongly induce uPA expression in the mesolimbic dopaminergic pathway. In this study, doxycycline-regulatable lentiviruses expressing either uPA, a dominant-negative form of uPA, or non-regulatable lentiviruses expressing small interfering RNAs (siRNAs) targeted against uPA have been prepared and injected into the ventral tegmental area (VTA) of rat brains. Over-expression of uPA in the VTA induces doxycycline-dependent expression of its receptor, uPAR, but not its inhibitor, plasminogen activator inhibitor-1 (PAI-1). uPAR expression in the VTA is repressed upon silencing of uPA with lentiviruses expressing siRNAs. In addition, over-expression of uPA in the VTA promotes a 15-fold increase in locomotion activity upon cocaine delivery. Animals expressing the dominant-negative form of uPA did not display such hyperlocomotor activity. These cocaine-induced behavioural changes, associated with uPA expression, could be suppressed in the presence of doxycycline or uPA-specific siRNAs expressing lentiviruses. These data strongly support the major role of urokinase in cocaine-mediated plasticity changes.

Cocaine-induced chest pain

Cocaine-associated chest pain is a clinical entity that crosses all socioeconomic groups and hence will be encountered by many physicians. The initial evaluation and treatment of cocaine-induced chest pain are similar to those of patients who have non-cocaine-induced chest pain, but there are several notable exceptions. This article reviews the pathophysiology, evaluation, management, and disposition decisions unique to patients presenting with cocaine-induced chest pain.