Cocaine-induced chest pain

Cardiovascular disease in HIV patients: recent advances in predicting and managing risk

INTRODUCTION

Cardiovascular disease (CVD) is one of the leading causes of mortality in virally suppressed people living with HIV (PLWH) and with an aging population, is likely to become one of the leading challenges in maintaining good health outcomes in HIV infection. However, factors driving the risk of CVD in PLWH are multiple and may be different from those of the general population, raising challenges to predicting and managing CVD risk in this population.

AREAS COVERED

In this review, we examine the relevant data regarding CVD in HIV infection including CVD prevalence, pathogenesis, and other contributing factors. We review the data regarding CVD risk prediction in PLWH and summarize factors, both general and HIV specific, that may influence CVD risk in this population. And finally, we discuss appropriate management of CVD risk in PLWH and explore potential therapeutic pathways which may mitigate CVD risk in the future in this population.

EXPERT OPINION

Following a comprehensive review of CVD risk in PLWH, we give our opinion on the primary issues in risk prediction and management of CVD in HIV infected individuals and discuss the future direction of CVD management in this population.

Phentermine: A Systematic Review for Plastic and Reconstructive Surgeons

PURPOSE

Phentermine is the most prescribed antiobesity drug in America, with 2.43 million prescriptions written in 2011. Case reports suggest there are anesthetic risks, such as refractory hypotension, involved with its perioperative use. Despite these risks and the frequency of phentermine use among plastic surgery patients, there are no published guidelines for the perioperative management of phentermine use in the plastic surgery literature. To address this patient safety issue, we performed a systematic review and provide management recommendations.

METHODS

A systematic review of the pharmacology of phentermine and the anesthetic risks involved with its perioperative use was undertaken using the search engines PubMed/MEDLINE, EMBASE, and Scopus.

RESULTS

A total of 251 citations were reviewed, yielding 4 articles that discussed perioperative phentermine use and complications with anesthesia. One was a review article, 2 were case reports, and 1 was a letter. Complications included hypotension, hypertension, hypoglycemia, hyperthermia, bradycardia, cardiac depression, and acute pulmonary edema.

CONCLUSIONS

The relationship between phentermine and anesthesia, if any, is unclear. Hypotension on induction of general anesthesia is the most reported complication of perioperative phentermine use. Specifically, phentermine-induced hypotension may be unresponsive to vasopressors that rely on catecholamine release, such as ephedrine. Therefore, the decision to perform surgery, especially elective surgery, in a patient taking phentermine should be made with caution. Because of the half-life of phentermine, we recommend discontinuing phentermine for at least 4 days prior to surgery. This differs from the classic 2-week discontinuation period recommended for "fen-phen." The patient should be made aware of the increased risk of surgery, and a skilled anesthesiologist should monitor intraoperative blood pressure and body temperature for signs of autonomic derailment.

Epicardial coronary arteries in khat chewers presenting with myocardial infarction

Background. Khat chewing is a common habit in Yemen despite increased evidence of its negative impact on the cardiovascular system. Aims. We aimed to study the epicardial coronary arteries in khat chewers presenting with myocardial infarction (AMI). Materials and Methods. A descriptive, cross-sectional study was conducted between November 2008 and May 2009 in Yemen. AMI patients who underwent coronary angiogram were enrolled and divided into groups (gp): gp1 (diabetic and khat chewers), gp2 (khat chewers and nondiabetic), and gp3 (diabetic and non-khat users). Results. Of 347 AMI patients 63%, 21%, and 16% were in gp 2, 3, and 1, respectively. Khat chewers were younger in comparison to non-khat users. Group 3 patients were more likely to have multivessel disease, severe left anterior descending (LAD), right coronary artery (RCA) stenosis and total RCA, and left circumflex (Lcx) occlusion compared to other groups. Group 1 patients were more likely to have total LAD occlusion and severe Lcx lesions. In multivariate analysis, age, diabetes mellitus, and smoking were significant independent predictors for significant coronary artery lesions; however, khat chewing did not show such association. Conclusions. Coronary spasm is the main mechanism of AMI in khat chewers. The impact of our finding for risk stratification and management warrants further studies.

Preoperative screening and case cancellation in cocaine-abusing veterans scheduled for elective surgery

Background. Perioperative management of cocaine-abusing patients scheduled for elective surgery varies widely based on individual anecdotes and personal experience. Methods. Chiefs of the anesthesia departments in the Veterans Affairs (VA) health system were surveyed to estimate how often they encounter surgical patients with cocaine use. Respondents were asked about their screening criteria, timing of screening, action resulting from positive screening, and if they have a formal policy for management of these patients. Interest in the development of VA guidelines for the perioperative management of patients with a history of cocaine use was also queried. Results. 172 VA anesthesia departments' chiefs were surveyed. Response rate was 62%. Over half of the facilities see cocaine-abusing patients at least once a week (52%). Two thirds of respondents canceled or delayed patients with a positive screen regardless of clinical symptoms. Only eleven facilities (10.6%) have a formal policy. The majority of facilities (80%) thought that having formal guidelines for perioperative management of cocaine-abusing patients would be helpful to some extent. Results. 172 VA anesthesia departments' chiefs were surveyed. Response rate was 62%. Over half of the facilities see cocaine-abusing patients at least once a week (52%). Two thirds of respondents canceled or delayed patients with a positive screen regardless of clinical symptoms. Only eleven facilities (10.6%) have a formal policy. The majority of facilities (80%) thought that having formal guidelines for perioperative management of cocaine-abusing patients would be helpful to some extent. Conclusions. There is a general consensus that formal guidelines would be helpful. Further studies are needed to help formulate evidence-based guidelines for managing patients screening positive for cocaine prior to elective surgery.

Rethinking cocaine-associated chest pain and acute coronary syndromes

Every year more than 500,000 patients present to the emergency department with cocaine-associated complications, most commonly chest pain. Many of these patients undergo extensive work-up and treatment. Much of the evidence regarding cocaine's cardiovascular effects, as well as the current management of cocaine-associated chest pain and acute coronary syndromes, is anecdotally derived and based on studies written more than 2 decades ago that involved only a few patients. Newer studies have brought into question many of the commonly held theories and practices regarding the etiology, diagnosis, and treatment of this common clinical scenario. However, there continues to be a paucity of prospective, randomized trials addressing this topic as it relates to clinical outcomes. We searched PubMed for English-language articles from 1960 to 2011 using the keywords cocaine, chest pain, coronary arteries, myocardial infarction, emergency department, cardiac biomarkers, electrocardiogram, coronary computed tomography, observation unit, β-blockers, benzodiazepines, nitroglycerin, calcium channel blockers, phentolamine, and cardiomyopathy; including various combinations of these terms. We reviewed the abstracts to confirm relevance, and then full articles were extracted. References from extracted articles were also reviewed for relevant articles. In this review, we critically evaluate the limited historical evidence underlying the current teachings on cocaine's cardiovascular effects and management of cocaine-associated chest pain. We aim to update the reader on more recent, albeit small, studies on the emergency department evaluation and clinical and pharmacologic management of cocaine-associated chest pain. Finally, we summarize recent guidelines and review an algorithm based on the current best evidence.

A case of large pericardial and pleural effusions associated with pulmonary emboli in a user of crack cocaine

We submit here an unusual case in which a user of crack cocaine presented with progressive dyspnea of subacute duration and was subsequently found to have concurrent pericardial and pleural effusions and pulmonary emboli. To our knowledge, there is only one prior case report that describes a potential causal relationship between crack cocaine and the development of a pleural effusion, via an eosinophilic process. In contrast in our patient, the most probable mechanism is that crack cocaine induced a prothrombotic state that promoted formation of pulmonary emboli, which are known to be directly associated with exudative pleural or pericardial effusions. An alternative hypothesis is that sympathetic activation or neurostimulation, which is mediated through release of adrenergic neurotransmitters by cocaine, may cause inflammatory changes in the pleura or pericardium. Finally, the pericardial effusion, pleural effusion, and pulmonary emboli could be concurrent but independent processes.

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

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

Acute myocardial infarction in young adults who abuse amphetamines

BACKGROUND

Case reports suggest a link between methamphetamine abuse and acute myocardial infarction (AMI), but no epidemiologic studies have examined this link. Our objective was to test the hypothesis that young adults who abuse amphetamines are at higher risk for AMI.

METHODS

In this study of 3,148,165 discharges from Texas hospitals in a quality indicators database during 2000-2003, among persons aged 18-44 years we identified 11,011 AMIs, defined according to the Agency for Healthcare Research and Quality's AMI mortality inpatient quality indicator.

RESULTS

In a multiple logistic regression analysis - while controlling for cocaine abuse, alcohol abuse, tobacco use, hypertension, diabetes mellitus, lipid disorders, obesity, congenital defects, and coagulation defects - amphetamine abuse was significantly associated with AMI (adjusted odds ratio=1.61; 95% CI=1.24-2.04, p=0.0004). The rate of AMIs among amphetamine abusers increased significantly from 2000 to 2003. The population attributable risk suggests that amphetamine abuse is responsible for 0.2% of AMIs in the state of Texas. The geographical distribution of amphetamine abuse varied by region, with the prevalence being highest in the North Texas and Panhandle regions of Texas.

CONCLUSIONS

This modest, though statistically robust, association suggests that amphetamine abuse may play a role in AMI.

Years of potential life lost among heroin addicts 33 years after treatment

OBJECTIVE

To examine premature mortality in terms of years of potential life lost (YPLL) among a cohort of long-term heroin addicts.

METHOD

This longitudinal, prospective study followed a cohort of 581 male heroin addicts in California for more than 33 years. In the latest follow-up conducted in 1996/97, 282 subjects (48.5%) were confirmed as deceased by death certificates. YPLL before age 65 years was calculated by causes of death. Ethnic differences in YPLL were assessed among Whites, Hispanics, and African Americans.

RESULTS

On average, addicts in this cohort lost 18.3 years (SD=10.7) of potential life before age 65. Of the total YPLL for the cohort, 22.3% of the years lost was due to heroin overdose, 14.0% due to chronic liver disease, and 10.2% to accidents. The total YPLL and YPLL by death cause in addict cohort were significantly higher than that of US population. The YPLL among African Americans was significantly lower than that among Whites or Hispanics.

CONCLUSION

The YPLL among addicts was much higher than that in the national population; within the cohort, premature mortality was higher among Whites and Hispanics compared to African American addicts.