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Gresnigt FM, Gubbels NP, Riezebos RK. The current practice for cocaine-associated chest pain in the Netherlands. Toxicol Rep 2020; 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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Sharma R, Kapoor N, Chaudhari KS, Scofield RH. Reversible Fulminant Hepatitis Secondary to Cocaine in the Setting of β-Blocker Use. J Investig Med High Impact Case Rep 2020; 8:2324709620924203. [PMID: 32434395 PMCID: PMC7243380 DOI: 10.1177/2324709620924203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background. Fulminant hepatitis is acute hepatic injury with severe decline in hepatic function manifested by encephalopathy, hypercoagulable state, jaundice, renal failure, hypoglycemia, or a constellation of these symptoms in patients without preexisting liver disease. Etiologies include viral infections, hepatotoxic drugs, autoimmune diseases, vaso-occlusive diseases, sepsis, and malignant infiltration. Case Report. A 56-year-old man presented with acute heart failure in the setting of cocaine use. The patient subsequently developed fulminant hepatic failure manifested by acute hypoglycemia, elevated liver enzyme, and worsening liver function, which resolved over 1 week with supportive care. The patient was on β-blocker, which was stopped during the admission. He was again admitted on several different occasion for cocaine-induced acute heart failure but did not develop hepatic failure as his β-blocker was discontinued. Discussion. Cocaine has been known to cause hepatotoxicity in humans. However, our patient developed fulminant hepatic failure in the setting of concomitant cocaine and β-blocker use likely secondary to unopposed α-adrenergic activity and ischemic hepatopathy. The patient did not develop hepatic failure on subsequent admissions with cocaine use after discontinuation of β-blockers.
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Affiliation(s)
- Rohan Sharma
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Nidhi Kapoor
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Banerji D, Alvi RM, Afshar M, Tariq N, Rokicki A, Mulligan CP, Zhang L, Hassan MO, Awadalla M, Groarke JD, Neilan TG. Carvedilol Among Patients With Heart Failure With a Cocaine-Use Disorder. JACC. HEART FAILURE 2019; 7:771-778. [PMID: 31466673 PMCID: PMC6719721 DOI: 10.1016/j.jchf.2019.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 06/19/2019] [Accepted: 06/20/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVES This study sought to assess the safety of carvedilol therapy among heart failure (HF) patients with a cocaine-use disorder (CUD). BACKGROUND Although carvedilol therapy is recommended among certain patients with HF, the safety and efficacy of carvedilol among HF patients with a CUD is unknown. METHODS This was a single-center study of hospitalized patients with HF. Cocaine use was self-reported or defined as having a positive urine toxicology. Patients were divided by carvedilol prescription. Subgroup analyses were performed by strata of ejection fraction (EF) ≤40%, 41% to 49%, or ≥50%. Major adverse cardiovascular events (MACE) were defined as cardiovascular mortality and 30-day HF readmission. RESULTS From a cohort of 2,578 patients hospitalized with HF in 2011, 503 patients with a CUD were identified, among whom 404 (80%) were prescribed carvedilol, and 99 (20%) were not. Both groups had similar characteristics; however, those prescribed carvedilol had a lower LVEF, heart rate, and N-terminal pro-B-type natriuretic peptide concentrations at admission and on discharge, and more coronary artery disease. Over a median follow-up of 19 months, there were 169 MACEs. The MACE rates were similar between the carvedilol and the non-carvedilol groups (32% vs. 38%, respectively; p = 0.16) and between those with a preserved EF (30% vs. 33%, respectively; p = 0.48) and were lower in patients with a reduced EF taking carvedilol (34% vs. 58%, respectively; p = 0.02). In a multivariate model, carvedilol therapy was associated with lower MACE among patients with HF with a CUD (hazard ratio: 0.67; 95% confidence interval; 0.481 to 0.863). CONCLUSIONS Our findings suggest that carvedilol therapy is safe for patients with HF with a CUD and may be effective among those with a reduced EF.
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Affiliation(s)
- Dahlia Banerji
- Cardiac MR PET CT Program, Department of Radiology, and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Raza M Alvi
- Cardiac MR PET CT Program, Department of Radiology, and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Bronx-Lebanon Hospital Center of Icahn School of Medicine at Mount Sinai, Bronx, New York.
| | - Maryam Afshar
- Bronx-Lebanon Hospital Center of Icahn School of Medicine at Mount Sinai, Bronx, New York
| | - Noor Tariq
- Department of Medicine, Division of Cardiology, Yale New Haven Hospital of Yale University School of Medicine, New Haven, Connecticut
| | - Adam Rokicki
- Cardiac MR PET CT Program, Department of Radiology, and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Connor P Mulligan
- Cardiac MR PET CT Program, Department of Radiology, and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lili Zhang
- Cardiac MR PET CT Program, Department of Radiology, and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Malek O Hassan
- Cardiac MR PET CT Program, Department of Radiology, and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Magid Awadalla
- Cardiac MR PET CT Program, Department of Radiology, and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John D Groarke
- Department of Medicine, Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tomas G Neilan
- Cardiac MR PET CT Program, Department of Radiology, and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Lo KB, Virk HUH, Lakhter V, Ram P, Gongora C, Pressman G, Figueredo V. Clinical Outcomes After Treatment of Cocaine-Induced Chest Pain with Beta-Blockers: A Systematic Review and Meta-Analysis. Am J Med 2019; 132:505-509. [PMID: 30562494 DOI: 10.1016/j.amjmed.2018.11.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 11/28/2018] [Accepted: 11/29/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Recent guidelines have suggested avoiding beta-blockers in the setting of cocaine-associated acute coronary syndrome. However, the available evidence is both scarce and conflicted. The purpose of this systematic review and meta-analysis is to investigate the evidence pertaining to the use of beta-blockers in the setting of acute cocaine-related chest pain and its implication on clinical outcomes. METHODS Electronic databases were systematically searched to identify literature relevant to patients with cocaine-associated chest pain who were treated with or without beta-blockers. We examined the end-points of in-hospital all-cause mortality and myocardial infarction. Pooled risk ratios (RR) and their 95% confidence intervals (CI) were calculated for all outcomes using a random-effects model. RESULTS Five studies with a total of 1447 patients were included. Our analyses found no differences between patients treated with or without beta-blockers for either myocardial infarction (RR 1.08; 95% CI, 0.61-1.91) or all-cause mortality (RR 0.75; 95% CI, 0.46-1.24). Heterogeneity among included studies was low to moderate. CONCLUSION This systematic review and meta-analysis suggests that beta-blocker use is not associated with adverse clinical outcomes in patients presenting with acute chest pain related to cocaine use.
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Affiliation(s)
| | | | - Vladimir Lakhter
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston
| | | | - Carlos Gongora
- Department of Cardiology, Mount Sinai St. Lukes West Hospital, New York, NY
| | - Gregg Pressman
- Department of Cardiology, Albert Einstein Medical Center, Philadelphia, Pa
| | - Vincent Figueredo
- Department of Cardiology, Albert Einstein Medical Center, Philadelphia, Pa
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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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Barison A, Aquaro GD, Seferović PM, Emdin M. Beta-blockers: A real antidote for cocaine-related heart disease? Int J Cardiol 2019; 277:198-199. [DOI: 10.1016/j.ijcard.2018.10.003] [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: 09/26/2018] [Accepted: 10/01/2018] [Indexed: 10/28/2022]
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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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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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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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10
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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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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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12
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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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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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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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Espana Schmidt C, Pastori L, Pekler G, Visco F, Mushiyev S. Early use of beta blockers in patients with cocaine associated chest pain. IJC HEART & VASCULATURE 2015; 8:167-169. [PMID: 28785697 PMCID: PMC5497278 DOI: 10.1016/j.ijcha.2015.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 06/12/2015] [Indexed: 10/26/2022]
Abstract
BACKGROUND The most common symptom of cocaine abuse is chest pain. Cocaine induced chest pain (CICP) shares patho-physiological pathways with the acute coronary syndromes (ACS). A key event is the increase of activity of the adrenergic system. Beta blockers (BBs), a cornerstone in the treatment of ACS, are felt to be contraindicated in the patient with CICP due to a potential of an "unopposed alpha adrenergic effect (UAE)". OBJECTIVES Identify signs of UAE and in-hospital complications in patients who received BB while having cocaine induced chest pain. METHODS We performed a retrospective review of 378 patients admitted to a medical unit because of CICP. Twenty six of these were given a BB at the time of admission while having CICP. We compared these patients to a control group paired by age, sex, race and history of hypertension who did not received a BB while having CICP. Blood pressure, heart rate, length of stay and in-hospital cardiovascular complications were compared. RESULTS No statistically significant differences were found between the two groups except for a longer length of stay in the case group. This was felt to be due to unrelated causes. CONCLUSIONS This study does not support the presence of an UAE in patients with continuing CICP and treated early with BB. There were no in-hospital cardiovascular complications in the group of patients who had an early dose of BB while having CICP. IMPLICATIONS BB appeared safe when given early on admission to patients with CICP.
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Affiliation(s)
- Christian Espana Schmidt
- Department of Medicine, Metropolitan Hospital Center/New York Medical College, New York, NY, United States
| | - Luciano Pastori
- Department of Medicine, Metropolitan Hospital Center/New York Medical College, New York, NY, United States
| | - Gerald Pekler
- Unit of Cardiology, Department of Medicine, Metropolitan Hospital Center/New York Medical College, New York, NY, United States
| | - Ferdinand Visco
- Unit of Cardiology, Department of Medicine, Metropolitan Hospital Center/New York Medical College, New York, NY, United States
| | - Savi Mushiyev
- Unit of Cardiology, Department of Medicine, Metropolitan Hospital Center/New York Medical College, New York, NY, United States
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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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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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