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Pezel T, Dillinger JG, Trimaille A, Delmas C, Piliero N, Bouleti C, Pommier T, El Ouahidi A, Andrieu S, Lattuca B, Rossanaly Vasram R, Fard D, Noirclerc N, Bonnet G, Goralski M, Elbaz M, Deney A, Schurtz G, Docq C, Roubille F, Fauvel C, Bochaton T, Aboyans V, Boccara F, Puymirat E, Batisse A, Steg G, Vicaut E, Henry P. Prevalence and impact of recreational drug use in patients with acute cardiovascular events. Heart 2023; 109:1608-1616. [PMID: 37582633 DOI: 10.1136/heartjnl-2023-322520] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 04/26/2023] [Indexed: 08/17/2023] Open
Abstract
OBJECTIVE While recreational drug use is a risk factor for cardiovascular events, its exact prevalence and prognostic impact in patients admitted for these events are not established. We aimed to assess the prevalence of recreational drug use and its association with in-hospital major adverse events (MAEs) in patients admitted to intensive cardiac care units (ICCU). METHODS In the Addiction in Intensive Cardiac Care Units (ADDICT-ICCU) study, systematic screening for recreational drugs was performed by prospective urinary testing all patients admitted to ICCU in 39 French centres from 7 to 22 April 2021. The primary outcome was prevalence of recreational drug detection. In-hospital MAEs were defined by death, resuscitated cardiac arrest, or haemodynamic shock. RESULTS Of 1499 consecutive patients (63±15 years, 70% male), 161 (11%) had a positive test for recreational drugs (cannabis 9.1%, opioids 2.1%, cocaine 1.7%, amphetamines 0.7%, 3,4-methylenedioxymethamphetamine (MDMA) 0.6%). Only 57% of these patients declared recreational drug use. Patients who used recreational drugs exhibited a higher MAE rate than others (13% vs 3%, respectively, p<0.001). Recreational drugs were associated with a higher rate of in-hospital MAEs after adjustment for comorbidities (OR 8.84, 95% CI 4.68 to 16.7, p<0.001). After adjustment, cannabis, cocaine, and MDMA, assessed separately, were independently associated with in-hospital MAEs. Multiple drug detection was frequent (28% of positive patients) and associated with an even higher incidence of MAEs (OR 12.7, 95% CI 4.80 to 35.6, p<0.001). CONCLUSION The prevalence of recreational drug use in patients hospitalised in ICCU was 11%. Recreational drug detection was independently associated with worse in-hospital outcomes. CLINICAL TRIAL REGISTRATION NCT05063097.
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Affiliation(s)
- Théo Pezel
- Department of Cardiology, Hôpital Lariboisière, Assistance Publique - Hopitaux de Paris, Université Paris Cité, INSERM U 942, Paris, France
| | - Jean-Guillaume Dillinger
- Department of Cardiology, Hôpital Lariboisière, Assistance Publique - Hopitaux de Paris, Université Paris Cité, INSERM U 942, Paris, France
| | - Antonin Trimaille
- Department of Cardiovascular Medicine, Nouvel Hôpital Civil, Strasbourg University Hospital, Strasbourg, France
| | - Clément Delmas
- Intensive Cardiac Care Unit, University Hospital of Rangueil, Toulouse, France
| | - Nicolas Piliero
- Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Claire Bouleti
- Cardiology, University of Poitiers, Clinical Investigation Center (CIC) INSERM 1402, Poitiers University Hospital, Poitiers, France
| | | | - Amine El Ouahidi
- Department of Cardiology, University Hospital of Brest, Brest, France
| | | | - Benoit Lattuca
- Cardiology, Centre Hospitalier Universitaire de Nîmes, Montpellier University, Nimes, France
| | | | - Damien Fard
- Intensive Cardiac Care Unit, Hopital Henri Mondor, Creteil, France
| | - Nathalie Noirclerc
- Centre Hospitalier Annecy Genevois, Epagny Metz-Tessy, Rhône-Alpes, France
| | - Guillaume Bonnet
- Assistance Publique Hopitaux de Marseille, Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, Provence-Alpes-Côte d'Azu, France
- Unité de Recherche Clinique, Groupe hospitalier Lariboisiere Fernand-Widal, Paris, Île-de-France, France
| | | | - Meyer Elbaz
- Intensive Cardiac Care Unit, University Hospital of Rangueil, Toulouse, France
| | - Antoine Deney
- University Hospital Centre Toulouse, Toulouse, Midi-Pyrénées, France
| | | | - Clemence Docq
- Department of Cardiology, University Hospital of Lille, Lille, France
| | - Francois Roubille
- Cardiology Department, INI-CRT, CHU de Montpellier, PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France
| | - Charles Fauvel
- Rouen University Hospital, INSERM EnVI 1096, Rouen, France
| | - Thomas Bochaton
- Intensive Cardiological Care Division, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital and Inserm 1094, Limoges, France
| | - Franck Boccara
- Cardiology, Sorbonne Université, GRC n°22, C²MV, Inserm UMR_S 938, Centre de Recherche Saint-Antoine, Institut Hospitalo-Universitaire de Cardio-métabolisme et Nutrition (ICAN), Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine Service de Cardiologie, Paris, France
| | | | - Anne Batisse
- Centre d'évaluation et d'information sur la pharmacodépendence de Paris, GH Lariboisiere Fernand-Widal, Paris, Île-de-France, France
| | - Gabriel Steg
- Cardiology, Université Paris-Cité, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, and Institut Universitaire de France, PARIS, France
| | - Eric Vicaut
- Unité de Recherche Clinique, Groupe hospitalier Lariboisiere Fernand-Widal, Paris, Île-de-France, France
| | - Patrick Henry
- Department of Cardiology, Hôpital Lariboisière, Assistance Publique - Hopitaux de Paris, Université Paris Cité, INSERM U 942, Paris, France
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Gresnigt FMJ, Smits ES, den Haan C, Riezebos RK, Franssen EJF, de Lange DW. The association of amfetamines and cathinones with acute coronary syndrome - a systematic review. Clin Toxicol (Phila) 2023; 61:336-345. [PMID: 37171152 DOI: 10.1080/15563650.2023.2191819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/07/2023] [Accepted: 03/11/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND It is well known that cocaine increases the risk of acute coronary syndrome. However, it is uncertain if the use of other stimulants, such as amfetamines and cathinones, is also related to acute coronary syndrome. OBJECTIVES To identify all reported cases of acute coronary syndrome related to the use of amfetamines and cathinones, the type of acute coronary syndrome, the atherothrombotic aetiology, and the mortality rate. METHODS A systematic literature search in PubMed, Embase database, Cochrane library, PsycInfo and Web of Science was performed from inception until 31 August 2022. All original articles in English or Dutch describing adult patients with acute coronary syndrome after the use of amfetamines or cathinones were included. The main outcome was the occurrence of acute coronary syndrome associated with amfetamine-type stimulants or cathinones. Data were collected and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS A total of 11,605 articles were identified, 56 of which met the inclusion criteria. A total of 160 patients presented with acute coronary syndrome after five different types of amfetamines, namely, amfetamine (n = 48), metamfetamine (n = 98), 3,4-methylenedioxymetamfetamine (n = 11), fenethylline (n = 2), and 4-fluoroamfetamine (n = 1). Khat chewing was associated with acute coronary syndrome (n = 4234), as were three different types of synthetic cathinones, namely, non-defined cathinones (n = 1), 4-methylmethcathinone (n = 1), and α-pyrrolidinopentiophenone (n = 1). In patients with a known acute coronary syndrome type (n = 157), ST-segment elevation myocardial infarction was diagnosed in 53 patients (75%) and non-ST-segment elevation myocardial infarction in 18 patients (25%). Of the ST-segment elevation myocardial infarction patients, 36% were diagnosed with significant coronary stenosis or thrombus. The mortality rate for khat-associated acute coronary syndrome, with more often male and older patients with fewer cardiovascular risk factors, was higher compared to non-khat-associated acute coronary syndrome. For amfetamine, metamfetamine, and 3,4-methylenedioxymetamfetamine, mortality associated with ST--segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction was 14% and 7%, respectively. Risk factors for acute coronary syndrome were infrequently reported, and risk stratification scores were not reported. CONCLUSION There is evidence that amfetamine-type stimulants and cathinones are associated with the occurrence of acute coronary syndrome. Khat chewing appears to be a risk factor for acute coronary syndrome. Amfetamine, metamfetamine, 3,4-methylenedioxymetamfetamine, fenethylline, 4-fluoroamfetamine, and synthetic cathinones were also reported in relation to acute coronary syndrome. However, this evidence is limited, of low quality and with a low number of reported cases. Further prospective studies need to be conducted.
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Affiliation(s)
- F M J Gresnigt
- Emergency Department, OLVG Amsterdam, Amsterdam, the Netherlands
- National Poison Control Centre, UMC Utrecht, Utrecht, the Netherlands
| | - E S Smits
- Emergency Department, OLVG Amsterdam, Amsterdam, the Netherlands
| | - C den Haan
- Hospital Library Department, OLVG Amsterdam, Amsterdam, the Netherlands
| | - R K Riezebos
- Heartcenter, OLVG Amsterdam, Amsterdam, the Netherlands
| | - E J F Franssen
- Hospital Library Department, OLVG Amsterdam, Amsterdam, the Netherlands
| | - D W de Lange
- National Poison Control Centre, UMC Utrecht, Utrecht, the Netherlands
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Gresnigt FM, Hulshof M, Franssen EJ, Vanhommerig JW, de Lange DW, Riezebos RK. Recreational drug use among young, hospitalized patients with acute coronary syndrome: A retrospective study. Toxicol Rep 2022; 9:1993-1999. [DOI: 10.1016/j.toxrep.2022.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/20/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022] Open
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Brgdar A, Gharbin J, Elawad A, Yi J, Sanchez J, Bishaw A, Taha ME, Ameyaw EE, Allen N, Prafulla M. Effects of Substance Use Disorder on In-Hospital Outcomes of Young Patients Presenting With a Cardiovascular Event: A Nationwide Analysis. Cureus 2022; 14:e22737. [PMID: 35386479 PMCID: PMC8969757 DOI: 10.7759/cureus.22737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2022] [Indexed: 11/20/2022] Open
Abstract
Background Substance use is widely prevalent among young adults and is associated with increased cardiovascular morbidity and mortality such as sudden cardiac arrest, acute coronary syndrome, arrhythmias, and cardiomyopathy. However, they are limited studies analyzing the impact of substance use disorder on in-hospital outcomes among young patients with cardiovascular events. Methods All patients aged 18-39 years admitted primarily for major cardiovascular events including acute myocardial infarction (AMI), arrhythmia, cardiac arrest, acute ischemic stroke, and venous thromboembolic events in 2019 were identified in the National Inpatient Sample database. They were then categorized into those with and without concomitant substance use disorder (SUD). The primary outcome was in-hospital mortality. Unadjusted and adjusted analysis was performed on appropriate variables of interest. Results Of 57,985 hospitalizations with cardiac events, 12,115 (20%) of young adults had concomitant SUD. SUD was significantly associated with cardiac arrest (OR 3.3; CI 2.4-4.4), atrial fibrillation (OR 1.5; CI 1.3-1.7), AMI (OR 1.3; CI 1.2-1.6), heart failure (OR 2.6; CI 2.4-3.0) (all p<0.05) despite a lower prevalence of traditional cardiovascular risk factors than non-users. Logistic regression showed acute kidney injury (aOR 1.5; CI 1.3-1.8; p<0.001) and inpatient mortality (aOR 1.6; CI 1.2-2.2; p<0.001) were also significantly higher in young patients presenting with cardiac events and concomitant SUD. There was no difference in the length of stay or incidence of gastrointestinal bleed between the two groups. Conclusion In young patients presenting with a cardiovascular event, concurrent substance use disorder was associated with increased in-hospital mortality despite significantly lower comorbidities.
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Cocaine-associated myocardial infarction: Features of diagnosis and treatment. J Electrocardiol 2021; 67:11-12. [PMID: 33984569 DOI: 10.1016/j.jelectrocard.2021.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/11/2021] [Accepted: 04/19/2021] [Indexed: 11/23/2022]
Abstract
Temporal relation of myocardial infarction with cocaine use was first reported in 1982, coronary spasm being the presumed aetiology since most patients presented with normal coronary arteries. However, severe and diffused coronary atherosclerosis is also common in cocaine users with myocardial infarction. The management of these patients presenting with chest pain includes therapy directed to antagonize sympathetic activation and mechanical reperfusion or thrombolytic therapy if ischaemia continues.
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Di Fusco SA, Rossini R, Flori M, Pollarolo L, Ingianni N, Malvezzi Caracciolo D'Aquino M, Galati G, Zilio F, Iorio A, Scotto di Uccio F, Lucà F, Gulizia MM, Ciccirillo F, Gabrielli D, Colivicchi F. Pathophysiology and management of recreational drug-related acute coronary syndrome: ANMCO position statement. J Cardiovasc Med (Hagerstown) 2021; 22:79-89. [PMID: 32858637 DOI: 10.2459/jcm.0000000000001091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Recreational drug use may cause coronary artery disease through several mechanisms. An increasing number of young patients with drug-related acute coronary syndrome have been reported over recent years. The present position statement reports the most recent epidemiological data on acute coronary syndrome in the setting of drug abuse, describes the main pathophysiological mechanisms underlying coronary artery disease and acute events in these patients, and provides practical recommendations on management and an overview of prognosis.
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Affiliation(s)
| | - Roberta Rossini
- U.O.C. Cardiologia, Azienda Ospedaliera Santa Croce e Carle, Cuneo
| | - Marco Flori
- U.O.C. Cardiologia, Presidio Ospedaliero Unico Urbino (PU)
| | - Luigi Pollarolo
- U.O.C Cardiologia, Ospedale Santo Spirito, Casale Monferrato (AL)
| | - Nadia Ingianni
- U.O.C. Cardiologia, Presidio Ospedaliero Paolo Borsellino, Marsala (TP)
| | | | - Giuseppe Galati
- Divisione di Cardiologia, IRCCS Ospedale San Raffaele, Milan
| | | | - Annamaria Iorio
- U.S.C. Cardiologia 2, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo
| | | | - Fabiana Lucà
- U.O.C. Cardiologia, A.O. Bianchi Melacrino Morelli, Reggio Calabria
| | - Michele Massimo Gulizia
- U.O.C. Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione 'Garibaldi', Catania
- Presidente Fondazione per il Tuo cuore, Firenze - Heart Care Foundation Onlus, Florence
| | | | - Domenico Gabrielli
- U.O.C Cardiologia, Ospedale Civile Augusto Murri, Area Vasta 4 Fermo, ASUR Marche, Fermo (AN), Italy
| | - Furio Colivicchi
- U.O.C. Cardiologia Clinica e Riabilitativa, P.O San Filippo Neri - ASL Roma1, Rome
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Gresnigt FMJ, Gubbels NP, Riezebos RK. The current practice for cocaine-associated chest pain in the Netherlands. Toxicol Rep 2021; 8:23-27. [PMID: 33384944 PMCID: PMC7770504 DOI: 10.1016/j.toxrep.2020.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 12/08/2020] [Accepted: 12/10/2020] [Indexed: 12/25/2022] Open
Abstract
Introduction Cocaine is considered a cardiovascular risk factor, yet it is not included in the frequently used risk stratification scores. Moreover, many guidelines provide limited advice on how to diagnose and treat cocaine-associated chest pain (CACP). This study aimed to determine the current practice for CACP patients in emergency departments and coronary care units throughout the Netherlands. Methods An anonymous online questionnaire-based survey was conducted among Dutch emergency physicians and cardiologists between July 2015 and February 2016. The questionnaire was based on the American Heart Association CACP treatment algorithm. Results A total of 214 subjects were enrolled and completed the questionnaire. All responders considered cocaine use a risk factor for developing acute coronary syndrome (ACS), nevertheless 74.4 % of emergency physicians and 81.1 % of cardiologists do not always question chest pain patients about drug use. Of all responders, 73.6 % never perform toxicology screening. Most responders (60 %) observe patients with CACP according to the European Society of Cardiology ACS guideline, and 24.3 % give these patients ß-blockers. Conclusion The current practice for CACP patients in most emergency departments and coronary care units in the Netherlands is not in line with the AHA scientific statement. Emergency physicians and cardiologists should be advised to routinely question all chest pain patients on drug history and be aware that the risk stratifications scores are not validated for CACP. Despite the AHA scientific statement of 2008, many respondents utilize ß-blockers for CACP patients, which is supported by published evidence since the statement appeared.
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Affiliation(s)
- Femke M J Gresnigt
- Emergency Physician, Emergency Department, OLVG Hospital, Oosterpark 9, 1091AC, Amsterdam, the Netherlands
| | - Nanda P Gubbels
- Emergency Medicine Resident, Emergency Department, OLVG Hospital, Oosterpark 9, 1091AC, Amsterdam, the Netherlands
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Ifedili I, Bob-Manuel T, Kadire SR, Heard B, John LA, Zambetti B, Heckle MR, Thomas F, Haji S, Khouzam RN, Reed GL, Ibebuogu UN. Cocaine Positivity in ST-Elevation Myocardial Infarction: A True or False Association. Perm J 2019; 23:18-048. [PMID: 30939276 DOI: 10.7812/tpp/18-048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Every year, more than 500,000 US Emergency Department visits are associated with cocaine use. People who use cocaine tend to have a lower incidence of true ST-elevation myocardial infarction (STEMI). OBJECTIVE To identify the factors associated with true STEMI in patients with cocaine-positive (CPos) findings. METHODS We retrospectively analyzed 1144 consecutive patients with STEMI between 2008 and 2013. True STEMI was defined as having a culprit lesion on coronary angiogram. Multivariate and univariate analyses were used to identify risk factors and create a predictive model. RESULTS A total of 64 patients with suspected STEMI were CPos (mean age 53.1 ± 11.2 years; male = 80%). True STEMI was diagnosed in 34 patients. Patients with CPos true STEMI were more likely to be uninsured than those with false STEMI (61.8% vs 34.5%, p = 0.03) and have higher peak troponin levels (21.1 ng/mL vs 2.12 ng/mL, p = < 0.01) with no difference in mean age between the 2 groups (p = 0.24). In multivariate analyses, independent predictors of true STEMI in patients with CPos findings included age older than 65 years (odds ratio [OR] = 19.3, 95% confidence iterval [CI] = 1.2-318.3), lack of health insurance (OR = 4.9, 95% CI = 1.2-19.6), and troponin level higher than 0.05 (OR = 24.0, 95% CI = 2.6-216.8) (all p < 0.05). A multivariate risk score created with a C-statistic of 82% (95% CI = 71-93) significantly improved the identification of patients with true STEMI. CONCLUSION Among those with suspected STEMI, patients with CPos findings had a higher incidence of false STEMI. Older age, lack of health insurance, and troponin levels outside of defined limits were associated with true STEMI in this group.
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Affiliation(s)
- Ikechukwu Ifedili
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | | | - Siri R Kadire
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Britteny Heard
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Leah A John
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Benjamin Zambetti
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Mark R Heckle
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Fridtjof Thomas
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Showkat Haji
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Rami N Khouzam
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Guy L Reed
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Uzoma N Ibebuogu
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
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Shin D, Lee ES, Bohra C, Kongpakpaisarn K. In-Hospital and Long-Term Outcomes of Beta-Blocker Treatment in Cocaine Users: A Systematic Review and Meta-analysis. Cardiol Res 2019; 10:40-47. [PMID: 30834058 PMCID: PMC6396807 DOI: 10.14740/cr831] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 02/08/2019] [Indexed: 11/11/2022] Open
Abstract
Background Although β-blocker treatment is generally contraindicated in patients presenting with acute cocaine intoxication due to concern for unopposed α-receptor stimulation, some studies have reported that β-blocker treatment did not increase adverse events in these patients. As this treatment is still controversial, we performed a meta-analysis of observational studies on this topic. Methods By searching three electronic databases (MEDLINE, EMBASE, and the Cochrane Library) from their inception to June 11, 2018, we identified eight observational studies with 2,048 patients who presented to hospital with cocaine-associated chest pain or after recent cocaine use. Outcomes of interest were myocardial necrosis or infarction (MI) and death during hospital stay or follow-up. Pooled relative risks (RRs) with 95% confidence intervals (CIs) were calculated by using a random-effects meta-analysis based on the DerSimonian-Laird method. Results Among patients presenting with cocaine-associated chest pain or recent cocaine use, there was no significant difference in in-hospital all-cause mortality (RR, 0.59; 95% CI, 0.24 - 1.47) and MI (RR, 1.24; 95% CI, 0.74 - 2.06) between patients who did and did not receive β-blocker treatment during their hospital stay. During long-term follow-up (mean 2.6 years), there was no significant difference in all-cause mortality (RR, 0.79; 95% CI, 0.44 - 1.41) and MI (RR, 0.96; 95% CI, 0.40 - 2.33) between the two groups. Conclusions These results suggest that β-blocker treatment in patients presenting with cocaine intoxication may not be as harmful as originally believed. Further clinical studies are needed to investigate this topic.
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Affiliation(s)
- Doosup Shin
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL 33606, USA
| | - Eun Sun Lee
- Department of Internal Medicine, Weiss Memorial Hospital, Chicago, IL 60640, USA
| | - Chandrashekar Bohra
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL 33606, USA
| | - Kullatham Kongpakpaisarn
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL 33606, USA
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Clinical outcomes of Β-blocker therapy in cocaine-associated heart failure. Int J Cardiol 2019; 277:153-158. [DOI: 10.1016/j.ijcard.2018.08.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/10/2018] [Accepted: 08/17/2018] [Indexed: 01/21/2023]
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Kim ST, Park T. Acute and Chronic Effects of Cocaine on Cardiovascular Health. Int J Mol Sci 2019; 20:ijms20030584. [PMID: 30700023 PMCID: PMC6387265 DOI: 10.3390/ijms20030584] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 01/26/2019] [Accepted: 01/27/2019] [Indexed: 01/19/2023] Open
Abstract
Cardiac complications resulting from cocaine use have been extensively studied because of the complicated pathophysiological mechanisms. This study aims to review the underlying cellular and molecular mechanisms of acute and chronic effects of cocaine on the cardiovascular system with a specific focus on human studies. Studies have consistently reported the acute effects of cocaine on the heart (e.g., electrocardiographic abnormalities, acute hypertension, arrhythmia, and acute myocardial infarction) through multifactorial mechanisms. However, variable results have been reported for the chronic effects of cocaine. Some studies found no association of cocaine use with coronary artery disease (CAD), while others reported its association with subclinical coronary atherosclerosis. These inconsistent findings might be due to the heterogeneity of study subjects with regard to cardiac risk. After cocaine use, populations at high risk for CAD experienced coronary atherosclerosis whereas those at low risk did not experience CAD, suggesting that the chronic effects of cocaine were more likely to be prominent among individuals with higher CAD risk. Studies also suggested that risky behaviors and cardiovascular risks may affect the association between cocaine use and mortality. Our study findings highlight the need for education regarding the deleterious effects of cocaine, and access to interventions for cocaine abusers.
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Affiliation(s)
- Sung Tae Kim
- Department of Pharmaceutical Engineering, Inje University, Gimhae 50834, Korea.
| | - Taehwan Park
- Pharmacy Administration, St. Louis College of Pharmacy, St. Louis, MO 63110, USA.
- Center for Health Outcomes Research and Education, St. Louis College of Pharmacy, St. Louis, MO 63110, USA.
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Pocar M, Airoldi F, Tavano D. Asymptomatic three-vessel total coronary occlusions and acute ischemic shock in a cocaine addict. J Cardiovasc Med (Hagerstown) 2018; 19:671-673. [DOI: 10.2459/jcm.0000000000000710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Pham D, Addison D, Kayani W, Misra A, Jneid H, Resar J, Lakkis N, Alam M. Outcomes of beta blocker use in cocaine-associated chest pain: a meta-analysis. Emerg Med J 2018; 35:559-563. [PMID: 29921621 PMCID: PMC7529122 DOI: 10.1136/emermed-2017-207065] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 05/16/2018] [Accepted: 05/30/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Beta blockers (β-blockers) remain a standard therapy in the early treatment of acute coronary syndromes. However, β-blocker therapy in patients with cocaine-associated chest pain (CACP) continues to be an area of debate due to the potential risk of unopposed α-adrenergic stimulation and coronary vasospasm. Therefore, we performed a systematic review and meta-analysis of available studies to compare outcomes of β-blocker versus no β-blocker use among patients with CACP. METHODS We searched the MEDLINE and EMBASE databases through September 2016 using the keywords 'beta blocker', 'cocaine' and commonly used β-blockers ('atenolol', 'bisoprolol', 'carvedilol', 'esmolol', 'metoprolol' and 'propranolol') to identify studies evaluating β-blocker use among patients with CACP. We specifically focused on studies comparing outcomes between β-blocker versus no β-blocker usage in patients with CACP. Studies without a comparison between β-blocker and no β-blocker use were excluded. Outcomes of interest included non-fatal myocardial infarction (MI) and all-cause mortality. Quantitative data synthesis was performed using a random-effects model and heterogeneity was assessed using Q and I2statistics. RESULTS A total of five studies evaluating 1794 subjects were included. Overall, there was no significant difference on MI in patients with CACP on β-blocker versus no β-blocker (OR 1.36, 95% CI 0.68 to 2.75; p=0.39). Similarly, there was no significant difference in all-cause mortality in patients on β-blocker versus no β-blocker (OR 0.68, 95% CI 0.26 to 1.79; p=0.43). CONCLUSIONS In patients presenting with acute chest pain and underlying cocaine, β-blocker use does not appear to be associated with an increased risk of MI or all-cause mortality.
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Affiliation(s)
- Don Pham
- Department of Medicine, Division of Cardiovascular Medicine, John Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel Addison
- Department of Medicine, Division of Cardiovascular Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Division of Cardiovascular Medicine, Ohio State University, Columbus, Ohio, USA
| | - Waleed Kayani
- Department of Medicine, Division of Cardiovascular Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Arunima Misra
- Department of Medicine, Division of Cardiovascular Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Hani Jneid
- Department of Medicine, Division of Cardiovascular Medicine, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Division of Cardiovascular Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Jon Resar
- Department of Medicine, Division of Cardiovascular Medicine, John Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nassir Lakkis
- Department of Medicine, Division of Cardiovascular Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Mahboob Alam
- Department of Medicine, Division of Cardiovascular Medicine, Baylor College of Medicine, Houston, Texas, USA
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14
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Gunja A, Stanislawski MA, Barón AE, Maddox TM, Bradley SM, Vidovich MI. The implications of cocaine use and associated behaviors on adverse cardiovascular outcomes among veterans: Insights from the VA Clinical Assessment, Reporting, and Tracking (CART) Program. Clin Cardiol 2018; 41:809-816. [PMID: 29652077 DOI: 10.1002/clc.22961] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/22/2018] [Accepted: 04/04/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cocaine use has been associated with adverse cardiovascular outcomes in patients with coronary artery disease (CAD). It is unclear whether this is due to direct effects of cocaine or other factors. HYPOTHESIS Cocaine use is associated with worse outcomes in patients undergoing cardiac catheterization METHODS: We used the Veterans Affairs database to identify veterans undergoing coronary catheterization between 2007 and 2014. We analyzed association between cocaine use and 1-year all-cause mortality, myocardial infarction (MI), and cerebrovascular accident (CVA) among veterans with obstructive CAD (N = 122 035). To explore factors contributing to these associations, we sequentially adjusted for cardiac risk factors, risky behaviors, and clinical conditions directly affected by cocaine. RESULTS 3082 (2.5%) veterans were cocaine users. Cocaine users were younger (median 58.2 vs 65.3 years; P < 0.001), more likely to be African American (58.9% vs 10.6%; P < 0.001), and had fewer traditional cardiac risk factors. After adjustment for cardiac risk factors, cocaine was associated with increased risk of mortality (HR: 1.23, 95% CI: 1.08-1.39), MI (HR: 1.40, 95% CI: 1.07-1.83), and CVA (HR: 1.88, 95% CI: 1.38-2.57). With continued adjustment, increased CVA risk remained significantly associated with cocaine use, whereas MI risk was mediated by risky behaviors and mortality was fully explained by conditions directly affected by cocaine. CONCLUSIONS Cocaine use is associated with adverse cardiac events in veterans with CAD. Contributors to this association are multifaceted and specific to individual cardiovascular outcomes, including associated risky behaviors and direct effects of cocaine. Effective intervention programs to reduce cardiac events in this population will require multiple components addressing these factors.
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Affiliation(s)
- Ateka Gunja
- Division of Cardiology, University of Illinois at Chicago.,Division of Cardiology, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois
| | | | - Anna E Barón
- University of Colorado School of Medicine, Aurora.,Colorado CV Health Care System, Denver, Colorado.,Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado.,Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora
| | - Thomas M Maddox
- Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri
| | - Steven M Bradley
- Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado.,Minneapolis Heart Institute, Center for Healthcare Delivery Innovation, and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota (work completed while at VA Eastern Colorado Health Care System)
| | - Mladen I Vidovich
- Division of Cardiology, University of Illinois at Chicago.,Division of Cardiology, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois
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15
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β-Blocker treatment and prognosis in acute coronary syndrome associated with cocaine consumption: The RUTI-Cocaine Study. Int J Cardiol 2018; 260:7-10. [DOI: 10.1016/j.ijcard.2018.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 12/07/2017] [Accepted: 02/02/2018] [Indexed: 11/18/2022]
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16
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Cocaine and acute coronary syndromes: Novel management insights for this clinical conundrum. Int J Cardiol 2018; 260:16-17. [PMID: 29622433 DOI: 10.1016/j.ijcard.2018.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 03/03/2018] [Indexed: 02/08/2023]
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17
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Lopez PD, Akinlonu A, Mene-Afejuku TO, Dumancas C, Saeed M, Cativo EH, Visco F, Mushiyev S, Pekler G. Improvement in clinical outcomes of patients with heart failure and active cocaine use after β-blocker therapy. Clin Cardiol 2018; 41:465-469. [PMID: 29663434 DOI: 10.1002/clc.22897] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 01/05/2018] [Accepted: 01/06/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Cocaine use has a high prevalence in the United States and can be associated with significant cardiovascular disease, even in asymptomatic users. β-Adrenergic receptor hyperactivation is the underlying pathophysiologic pathway of cocaine cardiotoxicity. β-Blocker therapy is controversial in patients with active cocaine use. HYPOTHESIS β-Blocker therapy is associated with clinical improvement in patients with heart failure despite active cocaine use. METHODS In a single-center, retrospective chart analysis, patients with newly diagnosed heart failure and active cocaine use who had been started on β-blocker therapy were reviewed. The New York Heart Association (NYHA) functional class and the left ventricular ejection fraction (LVEF) were recorded at baseline and after 12 monthsnthsnths of β-blocker use. Patients were excluded if they had been on prior β-blocker therapy, had other reasons for volume overload, had chronic kidney disease stages G4 or G5, or had a life expectancy <12 months. RESULTS Thirty-eight patients were identified; most were African American males. A statistically significant improvement was found in both NYHA functional class (P < 0.0001) and LVEF (P < 0.0001) after 12 months of β-blocker therapy. No major adverse cardiovascular events occurred in this population. CONCLUSIONS β-Blocker use in cocaine users with heart failure with a reduced ejection fraction is associated with a lower NYHA functional class and a higher LVEF at 12-month follow-up. No major adverse cardiovascular events were observed.
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Affiliation(s)
- Persio D Lopez
- Department of Medicine, Health+Hospitals/Metropolitan, New York, New York
| | - Adedoyin Akinlonu
- Department of Medicine, Health+Hospitals/Metropolitan, New York, New York
| | | | - Carissa Dumancas
- Department of Medicine, Health+Hospitals/Metropolitan, New York, New York
| | - Mohammed Saeed
- Department of Medicine, Health+Hospitals/Metropolitan, New York, New York
| | - Eder H Cativo
- Department of Medicine, Health+Hospitals/Metropolitan, New York, New York
| | - Ferdinand Visco
- Department of Medicine, Division of Cardiology, Health+Hospitals/Metropolitan, New York, New York
| | - Savi Mushiyev
- Department of Medicine, Division of Cardiology, Health+Hospitals/Metropolitan, New York, New York
| | - Gerald Pekler
- Department of Medicine, Division of Cardiology, Health+Hospitals/Metropolitan, New York, New York
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18
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DeFilippis EM, Singh A, Divakaran S, Gupta A, Collins BL, Biery D, Qamar A, Fatima A, Ramsis M, Pipilas D, Rajabi R, Eng M, Hainer J, Klein J, Januzzi JL, Nasir K, Di Carli MF, Bhatt DL, Blankstein R. Cocaine and Marijuana Use Among Young Adults With Myocardial Infarction. J Am Coll Cardiol 2018. [PMID: 29535062 DOI: 10.1016/j.jacc.2018.02.047] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Substance abuse is increasingly prevalent among young adults, but data on cardiovascular outcomes remain limited. OBJECTIVES The objectives of this study were to assess the prevalence of cocaine and marijuana use in adults with their first myocardial infarction (MI) at ≤50 years and to determine its association with long-term outcomes. METHODS The study retrospectively analyzed records of patients presenting with a type 1 MI at ≤50 years at 2 academic hospitals from 2000 to 2016. Substance abuse was determined by review of records for either patient-reported substance abuse during the week before MI or substance detection on toxicology screen. Vital status was identified by the Social Security Administration's Death Master File. Cause of death was adjudicated using electronic health records and death certificates. Cox modeling was performed for survival free from all-cause and cardiovascular death. RESULTS A total of 2,097 patients had type 1 MI (mean age 44.0 ± 5.1 years, 19.3% female, 73% white), with median follow-up of 11.2 years (interquartile range: 7.3 to 14.2 years). Use of cocaine and/or marijuana was present in 224 (10.7%) patients; cocaine in 99 (4.7%) patients, and marijuana in 125 (6.0%). Individuals with substance use had significantly lower rates of diabetes (14.7% vs. 20.4%; p = 0.05) and hyperlipidemia (45.7% vs. 60.8%; p < 0.001), but they were significantly more likely to use tobacco (70.3% vs. 49.1%; p < 0.001). The use of cocaine and/or marijuana was associated with significantly higher cardiovascular mortality (hazard ratio: 2.22; 95% confidence interval: 1.27 to 3.70; p = 0.005) and all-cause mortality (hazard ratio: 1.99; 95% confidence interval: 1.35 to 2.97; p = 0.001) after adjusting for baseline covariates. CONCLUSIONS Cocaine and/or marijuana use is present in 10% of patients with an MI at age ≤50 years and is associated with worse all-cause and cardiovascular mortality. These findings reinforce current recommendations for substance use screening among young adults with an MI, and they highlight the need for counseling to prevent future adverse events.
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Affiliation(s)
- Ersilia M DeFilippis
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Avinainder Singh
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sanjay Divakaran
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ankur Gupta
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bradley L Collins
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Biery
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Arman Qamar
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amber Fatima
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Mattheus Ramsis
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel Pipilas
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Roxanna Rajabi
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Monica Eng
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jon Hainer
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Josh Klein
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - James L Januzzi
- Cardiovascular Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Khurram Nasir
- Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida
| | - Marcelo F Di Carli
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deepak L Bhatt
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ron Blankstein
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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19
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Richards JR. Safety and Efficacy of Beta Blockers in Cocaine-Using Patients With Heart Failure. Am J Cardiol 2018; 121:393. [PMID: 29191569 DOI: 10.1016/j.amjcard.2017.10.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 10/23/2017] [Indexed: 10/18/2022]
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20
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Beta-blockers and Cocaine-Associated ST-Segment Elevation Myocardial Infarction in an Inner-City Community. Am J Cardiol 2017; 120:e81. [PMID: 28087051 DOI: 10.1016/j.amjcard.2016.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 12/20/2016] [Accepted: 12/20/2016] [Indexed: 11/22/2022]
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Richards JR, Hollander JE, Ramoska EA, Fareed FN, Sand IC, Izquierdo Gómez MM, Lange RA. β-Blockers, Cocaine, and the Unopposed α-Stimulation Phenomenon. J Cardiovasc Pharmacol Ther 2016; 22:239-249. [PMID: 28399647 DOI: 10.1177/1074248416681644] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Cocaine abuse remains a significant worldwide health problem. Patients with cardiovascular toxicity from cocaine abuse frequently present to the emergency department for treatment. These patients may be tachycardic, hypertensive, agitated, and have chest pain. Several pharmacological options exist for treatment of cocaine-induced cardiovascular toxicity. For the past 3 decades, the phenomenon of unopposed α-stimulation after β-blocker use in cocaine-positive patients has been cited as an absolute contraindication, despite limited and inconsistent clinical evidence. In this review, the authors of the original studies, case reports, and systematic review in which unopposed α-stimulation was believed to be a factor investigate the pathophysiology, pharmacology, and published evidence behind the unopposed α-stimulation phenomenon. We also investigate other potential explanations for unopposed α-stimulation, including the unique and deleterious pharmacologic properties of cocaine in the absence of β-blockers. The safety and efficacy of the mixed β-/α-blockers labetalol and carvedilol are also discussed in relation to unopposed α-stimulation.
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Affiliation(s)
- John R Richards
- 1 Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA, USA
| | - Judd E Hollander
- 2 Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Edward A Ramoska
- 3 Department of Emergency Medicine, Drexel University, Philadelphia, PA, USA
| | - Fareed N Fareed
- 4 Emergency Medical Associates, EmCare Partners Group, Parsippany, NJ, USA
| | | | | | - Richard A Lange
- 7 Division of Cardiology, Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
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22
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Abstract
With each successive year, the number of Emergency Department (ED) visits related to illicit drug abuse has progressively increased. Cocaine is the most common illegal drug to cause a visit to the ED. Cocaine use results in a variety of pathophysiological changes with regards to the cardiovascular system, such as constriction of coronary vessels, dysfunction of vascular endothelium, decreased aortic elasticity, hemodynamic disruptions, a hypercoagulable state, and direct toxicity to myocardial and vascular tissue. The clinical course of patients with cocaine-induced chest pain (CCP) is often challenging, and electrocardiographic findings can be potentially misleading in terms of diagnosing a myocardial infarction. In addition, there is no current satisfactory study regarding outcomes of use of various pharmacological drug therapies to manage CCP. At present, calcium-channel blockers and nitroglycerin are two pharmacological agents that are advocated as first-line drugs for CCP management, although the role of labetalol has been controversial and warrants further investigation. We performed an extensive search of available literature through a large number of scholarly articles previously published and listed on Index Medicus. In this review, we put forward a concise summary of the current approach to a patient presenting to the ED with CCP and management of the clinical scenario. The purpose of this review is to summarize the understanding of cocaine's cardiovascular pathophysiology and to examine the current approach for proper evaluation and management of CCP.
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Shitole SG, Kayo N, Srinivas V, Alapati V, Nordin C, Southern W, Christia P, Faillace RT, Scheuer J, Kizer JR. Clinical Profile, Acute Care, and Middle-Term Outcomes of Cocaine-Associated ST-Segment Elevation Myocardial Infarction in an Inner-City Community. Am J Cardiol 2016; 117:1224-30. [PMID: 26897639 DOI: 10.1016/j.amjcard.2016.01.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 01/18/2016] [Accepted: 01/18/2016] [Indexed: 10/22/2022]
Abstract
Although cocaine is a well-recognized risk factor for coronary disease, detailed information is lacking regarding related behavioral and clinical features of cocaine-associated ST-segment elevation myocardial infarction (STEMI), particularly in socioeconomically disadvantaged urban settings. Nor are systematic or extended follow-up data available on outcomes for cocaine-associated STEMI in the contemporary era of percutaneous coronary intervention. We leveraged a prospective STEMI registry from a large health system serving an inner-city community to characterize the clinical features, acute management, and middle-term outcomes of cocaine-related versus cocaine-unrelated STEMI. Of the 1,003 patients included, 60% were black or Hispanic. Compared with cocaine-unrelated STEMI, cocaine-related STEMI (n = 58) was associated with younger age, male gender, lower socioeconomic score, current smoking, high alcohol consumption, and human immunodeficiency virus seropositivity but less commonly with diabetes or hypertension. Cocaine users less often received drug-eluting stents or β blockers at discharge. During median follow-up of 2.7 years, rates of death, death or any rehospitalization, and death or cardiovascular rehospitalization did not differ significantly between cocaine users and nonusers but were especially high for death or any hospitalization in the 2 groups (31.4 vs 32.4 per 100 person-years, p = 0.887). Adjusted hazard ratios for outcomes were likewise not significantly different. In conclusion, in this low-income community, cocaine use occurred in a substantial fraction of STEMI cases, who were younger than their nonuser counterparts but had more prevalent high-risk habits and exhibited similarly high rates of adverse outcomes. These data suggest that programs targeting cocaine abuse and related behaviors could contribute importantly to disease prevention in disadvantaged communities.
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Richards JR, Garber D, Laurin EG, Albertson TE, Derlet RW, Amsterdam EA, Olson KR, Ramoska EA, Lange RA. Treatment of cocaine cardiovascular toxicity: a systematic review. Clin Toxicol (Phila) 2016; 54:345-64. [PMID: 26919414 DOI: 10.3109/15563650.2016.1142090] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Cocaine abuse is a major worldwide health problem. Patients with acute cocaine toxicity presenting to the emergency department may require urgent treatment for tachycardia, dysrhythmia, hypertension, and coronary vasospasm, leading to pathological sequelae such as acute coronary syndrome, stroke, and death. OBJECTIVE The objective of this study is to review the current evidence for pharmacological treatment of cardiovascular toxicity resulting from cocaine abuse. METHODS MEDLINE, PsycINFO, Database of Abstracts of Reviews of Effects (DARE), OpenGrey, Google Scholar, and the Cochrane Library were searched from inception to November 2015. Articles on pharmacological treatment involving human subjects and cocaine were selected and reviewed. Evidence was graded using Oxford Centre for Evidence-Based Medicine guidelines. Treatment recommendations were compared to current American College of Cardiology/American Heart Association guidelines. Special attention was given to adverse drug events or treatment failure. The search resulted in 2376 articles with 120 eligible involving 2358 human subjects. Benzodiazepines and other GABA-active agents: There were five high-quality (CEBM Level I/II) studies, three retrospective (Level III), and 25 case series/reports (Level IV/V) supporting the use of benzodiazepines and other GABA-active agents in 234 subjects with eight treatment failures. Benzodiazepines may not always effectively mitigate tachycardia, hypertension, and vasospasm from cocaine toxicity. Calcium channel blockers: There were seven Level I/II, one Level III, and seven Level IV/V studies involving 107 subjects and one treatment failure. Calcium channel blockers may decrease hypertension and coronary vasospasm, but not necessarily tachycardia. Nitric oxide-mediated vasodilators: There were six Level I/II, one Level III, and 25 Level IV/V studies conducted in 246 subjects with 11 treatment failures and two adverse drug events. Nitroglycerin may lead to severe hypotension and reflex tachycardia. Alpha-adrenoceptor blocking drugs: There were two Level I studies and three case reports. Alpha-1 blockers may improve hypertension and vasospasm, but not tachycardia, although evidence is limited. Alpha-2-adrenoceptor agonists: There were two high-quality studies and one case report detailing the successful use of dexmedetomidine. Beta-blockers and β/α-blockers: There were nine Level I/II, seven Level III, and 34 Level IV/V studies of β-blockers, with 1744 subjects, seven adverse drug events, and three treatment failures. No adverse events were reported for use of combined β/α-blockers such as labetalol and carvedilol, which were effective in attenuating both hypertension and tachycardia. Antipsychotics: Seven Level I/II studies, three Level III studies, and seven Level IV/V case series and reports involving 168 subjects have been published. Antipsychotics may improve agitation and psychosis, but with inconsistent reduction in tachycardia and hypertension and risk of extrapyramidal adverse effects. Other agents: There was only one high level study of morphine, which reversed cocaine-induced coronary vasoconstriction but increased heart rate. Other agents reviewed included lidocaine, sodium bicarbonate, amiodarone, procainamide, propofol, intravenous lipid emulsion, propofol, and ketamine. CONCLUSIONS High-quality evidence for pharmacological treatment of cocaine cardiovascular toxicity is limited but can guide acute management of associated tachycardia, dysrhythmia, hypertension, and coronary vasospasm. Future randomized prospective trials are needed to evaluate new agents and further define optimal treatment of cocaine-toxic patients.
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Affiliation(s)
- John R Richards
- a Department of Emergency Medicine , University of California Davis Medical Center , Sacramento , CA , USA
| | - Dariush Garber
- a Department of Emergency Medicine , University of California Davis Medical Center , Sacramento , CA , USA
| | - Erik G Laurin
- a Department of Emergency Medicine , University of California Davis Medical Center , Sacramento , CA , USA
| | - Timothy E Albertson
- b Department of Internal Medicine, Divisions of Toxicology, Pulmonary and Critical Care , University of California Davis Medical Center , Sacramento , CA , USA
| | - Robert W Derlet
- a Department of Emergency Medicine , University of California Davis Medical Center , Sacramento , CA , USA
| | - Ezra A Amsterdam
- c Department of Internal Medicine, Division of Cardiology , University of California Davis Medical Center , Sacramento , CA , USA
| | - Kent R Olson
- d Departments of Medicine and Clinical Pharmacy , University of California, San Francisco, Medical Director, California Poison Control System, San Francisco Division , San Francisco , CA , USA
| | - Edward A Ramoska
- e Department of Emergency Medicine , Drexel University , Philadelphia , PA , USA
| | - Richard A Lange
- f Department of Internal Medicine, Division of Cardiology , Texas Tech University Health Sciences Center , El Paso , TX , USA
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Cardiovascular and Hepatic Toxicity of Cocaine: Potential Beneficial Effects of Modulators of Oxidative Stress. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2015; 2016:8408479. [PMID: 26823954 PMCID: PMC4707355 DOI: 10.1155/2016/8408479] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 10/19/2015] [Accepted: 11/01/2015] [Indexed: 12/20/2022]
Abstract
Oxidative stress (OS) is thought to play an important role in the pharmacological and toxic effects of various drugs of abuse. Herein we review the literature on the mechanisms responsible for the cardiovascular and hepatic toxicity of cocaine with special focus on OS-related mechanisms. We also review the preclinical and clinical literature concerning the putative therapeutic effects of OS modulators (such as N-acetylcysteine, superoxide dismutase mimetics, nitroxides and nitrones, NADPH oxidase inhibitors, xanthine oxidase inhibitors, and mitochondriotropic antioxidants) for the treatment of cocaine toxicity. We conclude that available OS modulators do not appear to have clinical efficacy.
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Long VP, Carnes CA. Treating cocaine cardiotoxicity: Does receptor subtype matter? Trends Cardiovasc Med 2015; 25:527-8. [DOI: 10.1016/j.tcm.2015.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 01/07/2015] [Indexed: 11/29/2022]
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Stankowski RV, Kloner RA, Rezkalla SH. Cardiovascular consequences of cocaine use. Trends Cardiovasc Med 2015; 25:517-26. [DOI: 10.1016/j.tcm.2014.12.013] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 12/03/2014] [Accepted: 12/17/2014] [Indexed: 11/28/2022]
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Pasupathy S, Air T, Dreyer RP, Tavella R, Beltrame JF. Systematic review of patients presenting with suspected myocardial infarction and nonobstructive coronary arteries. Circulation 2015; 131:861-70. [PMID: 25587100 DOI: 10.1161/circulationaha.114.011201] [Citation(s) in RCA: 578] [Impact Index Per Article: 64.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a puzzling clinical entity with no previous evaluation of the literature. This systematic review aims to (1) quantify the prevalence, risk factors, and 12-month prognosis in patients with MINOCA, and (2) evaluate potential pathophysiological mechanisms underlying this disorder. METHODS AND RESULTS Quantitative assessment of 28 publications using a meta-analytic approach evaluated the prevalence, clinical features, and prognosis of MINOCA. The prevalence of MINOCA was 6% [95% confidence interval, 5%-7%] with a median patient age of 55 years (95% confidence interval, 51-59 years) and 40% women. However, in comparison with those with myocardial infarction associated with obstructive coronary artery disease, the patients with MINOCA were more likely to be younger and female but less likely to have hyperlipidemia, although other cardiovascular risk factors were similar. All-cause mortality at 12 months was lower in MINOCA (4.7%; 95% confidence interval, 2.6%-6.9%) compared with myocardial infarction associated with obstructive coronary artery disease (6.7%, 95% confidence interval, 4.3%-9.0%). Qualitative assessment of 46 publications evaluating the underlying pathophysiology responsible for MINOCA revealed the presence of a typical myocardial infarct on cardiac magnetic resonance imaging in only 24% of patients, with myocarditis occurring in 33% and no significant abnormality in 26%. Coronary artery spasm was inducible in 27% of MINOCA patients, and thrombophilia disorders were detected in 14%. CONCLUSIONS MINOCA should be considered as a working diagnosis with multiple potential causes that require evaluation so that directed therapies may improve its guarded prognosis.
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Affiliation(s)
- Sivabaskari Pasupathy
- From Discipline of Medicine, University of Adelaide, South Australia (S.P., R.P.D., R.T., J.F.B.); Cardiology Department, Queen Elizabeth Hospital, Adelaide, South Australia (S.P., R.P.D., R.T., J.F.B.); Discipline of Psychiatry, University of Adelaide, South Australia (T.A.); Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, New Haven, CT (R.P.D.); Department of Internal Medicine, Yale School of Medicine, New Haven, CT (R.P.D.); and Cardiology Department, Lyell McEwin Hospital, Adelaide, South Australia (J.F.B.)
| | - Tracy Air
- From Discipline of Medicine, University of Adelaide, South Australia (S.P., R.P.D., R.T., J.F.B.); Cardiology Department, Queen Elizabeth Hospital, Adelaide, South Australia (S.P., R.P.D., R.T., J.F.B.); Discipline of Psychiatry, University of Adelaide, South Australia (T.A.); Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, New Haven, CT (R.P.D.); Department of Internal Medicine, Yale School of Medicine, New Haven, CT (R.P.D.); and Cardiology Department, Lyell McEwin Hospital, Adelaide, South Australia (J.F.B.)
| | - Rachel P Dreyer
- From Discipline of Medicine, University of Adelaide, South Australia (S.P., R.P.D., R.T., J.F.B.); Cardiology Department, Queen Elizabeth Hospital, Adelaide, South Australia (S.P., R.P.D., R.T., J.F.B.); Discipline of Psychiatry, University of Adelaide, South Australia (T.A.); Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, New Haven, CT (R.P.D.); Department of Internal Medicine, Yale School of Medicine, New Haven, CT (R.P.D.); and Cardiology Department, Lyell McEwin Hospital, Adelaide, South Australia (J.F.B.)
| | - Rosanna Tavella
- From Discipline of Medicine, University of Adelaide, South Australia (S.P., R.P.D., R.T., J.F.B.); Cardiology Department, Queen Elizabeth Hospital, Adelaide, South Australia (S.P., R.P.D., R.T., J.F.B.); Discipline of Psychiatry, University of Adelaide, South Australia (T.A.); Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, New Haven, CT (R.P.D.); Department of Internal Medicine, Yale School of Medicine, New Haven, CT (R.P.D.); and Cardiology Department, Lyell McEwin Hospital, Adelaide, South Australia (J.F.B.)
| | - John F Beltrame
- From Discipline of Medicine, University of Adelaide, South Australia (S.P., R.P.D., R.T., J.F.B.); Cardiology Department, Queen Elizabeth Hospital, Adelaide, South Australia (S.P., R.P.D., R.T., J.F.B.); Discipline of Psychiatry, University of Adelaide, South Australia (T.A.); Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, New Haven, CT (R.P.D.); Department of Internal Medicine, Yale School of Medicine, New Haven, CT (R.P.D.); and Cardiology Department, Lyell McEwin Hospital, Adelaide, South Australia (J.F.B.).
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Gili M, Ramírez G, Béjar L, López J. ¿Los trastornos por cocaína asociados al infarto agudo de miocardio son lo mismo que el infarto de miocardio asociado al consumo reciente de cocaína? Respuesta. Rev Esp Cardiol (Engl Ed) 2014. [DOI: 10.1016/j.recesp.2014.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Gili M, Ramírez G, Béjar L, López J. Is cocaine-associated acute myocardial infarction the same as myocardial infarction associated with recent cocaine consumption? Response. ACTA ACUST UNITED AC 2014; 67:965-6. [PMID: 25241026 DOI: 10.1016/j.rec.2014.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 06/26/2014] [Indexed: 11/15/2022]
Affiliation(s)
- Miguel Gili
- Unidad de Gestión Clínica de Medicina Preventiva, Vigilancia y Promoción de la Salud, Hospital Universitario Virgen Macarena, Seville, Spain; Departamento de Medicina Preventiva y Salud Pública, Universidad de Sevilla, Seville, Spain.
| | - Gloria Ramírez
- Unidad de Gestión Clínica de Medicina Preventiva, Vigilancia y Promoción de la Salud, Hospital Universitario Virgen Macarena, Seville, Spain; Departamento de Medicina Preventiva y Salud Pública, Universidad de Sevilla, Seville, Spain
| | - Luis Béjar
- Departamento de Medicina Preventiva y Salud Pública, Universidad de Sevilla, Seville, Spain
| | - Julio López
- Unidad de Gestión Clínica de Medicina Preventiva, Vigilancia y Promoción de la Salud, Hospital Universitario Virgen Macarena, Seville, Spain; Departamento de Medicina Preventiva y Salud Pública, Universidad de Sevilla, Seville, Spain
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Schurr JW, Gitman B, Belchikov Y. Controversial therapeutics: the β-adrenergic antagonist and cocaine-associated cardiovascular complications dilemma. Pharmacotherapy 2014; 34:1269-81. [PMID: 25224512 DOI: 10.1002/phar.1486] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- James W Schurr
- St. John's University College of Pharmacy and Health Sciences, Queens, New York
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Tai B, Hu L, Ghitza UE, Sparenborg S, VanVeldhuisen P, Lindblad R. Patient registries for substance use disorders. Subst Abuse Rehabil 2014; 5:81-6. [PMID: 25114612 PMCID: PMC4114906 DOI: 10.2147/sar.s64977] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This commentary discusses the need for developing patient registries of substance use disorders (SUD) in general medical settings. A patient registry is a tool that documents the natural history of target diseases. Clinicians and researchers use registries to monitor patient comorbidities, care procedures and processes, and treatment effectiveness for the purpose of improving care quality. Enactments of the Affordable Care Act 2010 and the Mental Health Parity and Addiction Equity Act 2008 open opportunities for many substance users to receive treatment services in general medical settings. An increased number of patients with a wide spectrum of SUD will initially receive services with a chronic disease management approach in primary care. The establishment of computer-based SUD patient registries can be assisted by wide adoption of electronic health record systems. The linkage of SUD patient registries with electronic health record systems can facilitate the advancement of SUD treatment research efforts and improve patient care.
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Affiliation(s)
- Betty Tai
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, USA
| | - Lian Hu
- The EMMES Corporation, Rockville, MD, USA
| | - Udi E Ghitza
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, USA
| | - Steven Sparenborg
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, USA
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