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Lucyk SN. Acute Cardiovascular Toxicity of Cocaine. Can J Cardiol 2022; 38:1384-1394. [PMID: 35697321 DOI: 10.1016/j.cjca.2022.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/22/2022] [Accepted: 05/02/2022] [Indexed: 11/27/2022] Open
Abstract
Cocaine is one of the most commonly abused drugs and represents a major public health concern. Cocaine users frequently present to the emergency department, with chest pain being the most common presenting complaint. The incidence of acute myocardial infarction in patients with cocaine-associated chest pain is often quoted as 6%, but it is highly variable depending on the included population. Risk assessment can be challenging in these patients; serial assessment of electrocardiograms and troponins is often required. This review focuses on the assessment and management of patients presenting with cocaine-associated chest pain and cardiotoxicity. Specific treatments are discussed, including benzodiazepines, nitroglycerin, calcium channel blockers, and phentolamine, and how treatment priorities differ from patients with noncocaine presentations. The use of beta-blockers in this population remains controversial, and the literature around its use is reviewed. The most recent literature and recommendations for the use of percutaneous coronary intervention and fibrinolytics in cocaine-associated myocardial infarction is discussed as well. Cocaine-associated dysrhythmias are suggested to be the cause of sudden cardiac death in some users. The pathophysiology and evidence-based treatments for dysrhythmias are reviewed. This review provides evidence-based recommendations for the assessment and management of patients presenting with cocaine-associated cardiovascular toxicity.
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Affiliation(s)
- Scott N Lucyk
- Poison and Drug Information Service, Alberta Health Services, Calgary, Alberta, Canada; Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Section of Clinical Pharmacology and Toxicology, Alberta Health Services, Calgary, Alberta, Canada.
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2
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Shariatnia S, Ziaratban M, Rajabi A, Salehi A, Abdi Zarrini K, Vakili M. Modeling the diagnosis of coronary artery disease by discriminant analysis and logistic regression: a cross-sectional study. BMC Med Inform Decis Mak 2022; 22:85. [PMID: 35351098 PMCID: PMC8966192 DOI: 10.1186/s12911-022-01823-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 03/24/2022] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Coronary artery disease (CAD) is one of the most significant cardiovascular diseases that requires accurate angiography to diagnose. Angiography is an invasive approach involving risks like death, heart attack, and stroke. An appropriate alternative for diagnosis of the disease is to use statistical or data mining methods. The purpose of the study was to predict CAD by using discriminant analysis and compared with the logistic regression. MATERIALS AND METHODS This cross-sectional study included 758 cases admitted to Fatemeh Zahra Teaching Hospital (Sari, Iran) for examination and coronary angiography for evaluation of CAD in 2019. A logistics discriminant, Quadratic Discriminant Analysis (QDA) and Linear Discriminant Analysis (LDA) model and K-Nearest Neighbor (KNN) were fitted for prognosis of CAD with the help of clinical and laboratory information of patients. RESULTS Out of the 758 examined cases, 250 (32.98%) cases were non-CAD and 508 (67.22%) were diagnosed with CAD disease. The results indicated that the indices of accuracy, sensitivity, specificity and area under the ROC curve (AUC) in the linear discriminant analysis (LDA) were 78.6, 81.3, 71.3, and 81.9%, respectively. The results obtained by the quadratic discriminant analysis were respectively 64.6, 88.2, 47.9, and 81%. The values of the metrics in K-nearest neighbor method were 74, 77.5, 63.7, and 82%, respectively. Finally, the logistic regression reached 77, 87.6, 55.6, and 82%, respectively for the evaluation metrics. CONCLUSIONS The LDA method is superior to the Quadratic Discriminant Analysis (QDA), K-Nearest Neighbor (KNN) and Logistic Regression (LR) methods in differentiating CAD patients. Therefore, in addition to common non-invasive diagnostic methods, LDA technique is recommended as a predictive model with acceptable accuracy, sensitivity, and specificity for the diagnosis of CAD. However, given that the differences between the models are small, it is recommended to use each model to predict CAD disease.
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Affiliation(s)
- Sahar Shariatnia
- Department of Biostatistics and Epidemiology, Faculty of Health, Golestan University of Medica Science, Gorgan, Iran
| | - Majid Ziaratban
- Department of Electrical Engineering, Faculty of Engineering, Golestan University, Gorgan, Iran
| | - Abdolhalim Rajabi
- Health Management and Social Development Research Center, Department of Biostatistics and Epidemiology, Faculty of Health, Golestan University of Medical Sciences, Gorgan, Iran
| | - Aref Salehi
- Ischemic Disorders Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Kobra Abdi Zarrini
- Intensive Care Unit of Fatemeh Zahra Hospital, Mazandaran University Medical Sciences, Sari, Iran
| | - Mohammadali Vakili
- Health Management and Social Development Research Center, Department of Biostatistics and Epidemiology, Faculty of Health, Golestan University of Medical Sciences, Gorgan, Iran.
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Kolossváry M, Celentano D, Gerstenblith G, Bluemke DA, Mandler RN, Fishman EK, Bhatia S, Chen S, Lai S, Lai H. HIV indirectly accelerates coronary artery disease by promoting the effects of risk factors: longitudinal observational study. Sci Rep 2021; 11:23110. [PMID: 34848791 PMCID: PMC8632934 DOI: 10.1038/s41598-021-02556-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 11/15/2021] [Indexed: 11/24/2022] Open
Abstract
Our objective was to assess whether human immunodeficiency virus (HIV)-infection directly or indirectly promotes the progression of clinical characteristics of coronary artery disease (CAD). 300 African Americans with asymptomatic CAD (210 male; age: 48.0 ± 7.2 years; 226 HIV-infected) who underwent coronary CT angiography at two time points (mean follow-up: 4.0 ± 2.3 years) were randomly selected from 1429 participants of a prospective epidemiological study between May 2004 and August 2015. We calculated Agatston-scores, number of coronary plaques and segment stenosis score (SSS). Linear mixed models were used to assess the effects of HIV-infection, atherosclerotic cardiovascular disease (ASCVD) risk, years of cocaine use on CAD. There was no significant difference in annual progression rates between HIV-infected and—uninfected regarding Agatston-scores (10.8 ± 25.1/year vs. 7.2 ± 17.8/year, p = 0.17), the number of plaques (0.2 ± 0.3/year vs. 0.3 ± 0.5/year, p = 0.11) or SSS (0.5 ± 0.8/year vs. 0.5 ± 1.3/year, p = 0.96). Multivariately, HIV-infection was not associated with Agatston-scores (8.3, CI: [− 37.2–53.7], p = 0.72), the number of coronary plaques (− 0.1, CI: [− 0.5–0.4], p = 0.73) or SSS (− 0.1, CI: [− 1.0–0.8], p = 0.84). ASCVD risk scores and years of cocaine-use significantly increased all CAD outcomes among HIV-infected individuals, but not among HIV-uninfected. Importantly, none of the HIV-medications were associated with any of the CAD outcomes. HIV-infection is not directly associated with CAD and therefore HIV-infected are not destined to have worse CAD profiles. However, HIV-infection may indirectly promote CAD progression as risk factors may have a more prominent role in the acceleration of CAD in these patients.
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Affiliation(s)
- Márton Kolossváry
- Department of Pathology, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology #301, Baltimore, MD, 21287, USA.,MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Városmajor str., Budapest, Hungary, 1122
| | - David Celentano
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, 614 Wolfe N Wolfe St, Baltimore, MD, 21205, USA
| | - Gary Gerstenblith
- Department of Medicine, Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD, 21205, USA
| | - David A Bluemke
- School of Medicine and Public Health, University of Wisconsin, 750 Highland Ave, Madison, WI, 53726, USA
| | - Raul N Mandler
- National Institute on Drug Abuse, National Institutes of Health, 10 Center Dr, Bethesda, MD, 20814, USA
| | - Elliot K Fishman
- Department of Radiology, Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD, 21205, USA
| | - Sandeepan Bhatia
- Institute of Human Virology, University of Maryland School of Medicine, 725 W Lombard St, Baltimore, MD, 21201, USA
| | - Shaoguang Chen
- Institute of Human Virology, University of Maryland School of Medicine, 725 W Lombard St, Baltimore, MD, 21201, USA
| | - Shenghan Lai
- Department of Pathology, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology #301, Baltimore, MD, 21287, USA. .,Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, 614 Wolfe N Wolfe St, Baltimore, MD, 21205, USA. .,Department of Medicine, Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD, 21205, USA. .,Department of Radiology, Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD, 21205, USA. .,Institute of Human Virology, University of Maryland School of Medicine, 725 W Lombard St, Baltimore, MD, 21201, USA.
| | - Hong Lai
- Department of Radiology, Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD, 21205, USA.,Institute of Human Virology, University of Maryland School of Medicine, 725 W Lombard St, Baltimore, MD, 21201, USA
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Chen DH, Kolossváry M, Chen S, Lai H, Yeh HC, Lai S. Long-term cocaine use is associated with increased coronary plaque burden - a pilot study. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2020; 46:805-811. [PMID: 32990047 DOI: 10.1080/00952990.2020.1807558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Background: There is a lack of research regarding whether prolonged use of cocaine would lead to increase of coronary plaque burden. Objectives: To study the effects of cocaine use on the coronary artery plaque volume. We hypothesize the longer the cocaine use, the greater the plaque burden. Methods: We used coronary computed tomography angiography to evaluate plaque volumes. The study included chronic (N = 33 with 27 HIV+) and non-cocaine users (N = 15 with 12 HIV+). Chronic cocaine use was defined as use by any route for at least 6 months, administered at least 4 times/month. The Student's t-test was used to compare the plaque volumes between chronic and non-cocaine users. Multivariable regression analysis adjusted for age, sex, body mass index, HIV status, cigarette smoking, diabetes, and total cholesterol was performed to determine the relationship between years of cocaine use and plaque volumes. Results: The total plaque volumes between groups showed no difference (p = .065). However, the total left anterior descending artery (LAD) plaque volume in the chronic cocaine group was significantly higher than that in the non-cocaine group (p = .047). For each year increase in cocaine use, total plaque volume and total LAD plaque volume increased by 7.23 mm3 (p = .013) and 4.56 mm3 (p = .001), respectively. In the multivariable analyses, both total plaque volume and total LAD plaque volume were significantly associated with years of cocaine use (p = .039 and 0.013, respectively). Conclusion: Prolonged cocaine use accelerates the development of sub-clinical atherosclerosis.
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Affiliation(s)
- Doris Hsinyu Chen
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health , Baltimore, USA
| | - Márton Kolossváry
- Department of Pathology, Johns Hopkins School of Medicine , Baltimore, USA.,MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University , Budapest, Hungary
| | - Shaoguang Chen
- Department of Pathology, Johns Hopkins School of Medicine , Baltimore, USA.,Institute of Human Virology, University of Maryland School of Medicine, University of Maryland School of Medicine , Baltimore, USA
| | - Hong Lai
- Department of Pathology, Johns Hopkins School of Medicine , Baltimore, USA.,Institute of Human Virology, University of Maryland School of Medicine, University of Maryland School of Medicine , Baltimore, USA
| | - Hsin-Chieh Yeh
- Division of General Internal Medicine, Johns Hopkins School of Medicine , Baltimore, USA
| | - Shenghan Lai
- Department of Pathology, Johns Hopkins School of Medicine , Baltimore, USA.,Institute of Human Virology, University of Maryland School of Medicine, University of Maryland School of Medicine , Baltimore, USA
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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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Sandfort V, Bluemke DA, Vargas J, Brinker JA, Gerstenblith G, Kickler T, Zheng G, Li J, Chen S, Lai H, Fishman EK, Lai S. Coronary Plaque Progression and Regression in Asymptomatic African American Chronic Cocaine Users With Obstructive Coronary Stenoses: A Preliminary Study. J Addict Med 2017; 11:126-137. [PMID: 28060223 PMCID: PMC5354964 DOI: 10.1097/adm.0000000000000282] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Although rapid progression of coronary atherosclerosis was observed in chronic cocaine users, it is unknown whether reduced cocaine use retards the progression of atherosclerosis. We investigated whether reduced cocaine use over a 12-month period was associated with coronary plaque regression in cocaine users. METHODS Fifteen African American chronic cocaine users with previously coronary computed tomography angiography (CCTA)-confirmed >50% coronary stenosis in Baltimore, Maryland, were enrolled in a study to investigate whether reduced cocaine use is associated with changes in coronary plaque burden over a 12-month period of cash-based incentive intervention, which was implemented to systematically reinforce cocaine abstinence. In addition to previous CCTA (preintervention), CCTA was performed at the intervention baseline and at postintervention. Plaque analyses were performed to determine the trajectory of plaque changes in the absence of intervention by comparing the preintervention with the intervention baseline studies; the trajectory of plaque changes associated with the intervention by comparing the intervention baseline with the postintervention studies; and (3) whether reduced cocaine use was independently associated with changes in coronary plaque burden. RESULTS During the 12-month cash-based incentive intervention period, cocaine use in participants was lower. The medians of noncalcified plaque indices were 37.8 (interquartile range [IQR] 29.3-44.0), 43.1 (IQR 38.3-49.0), and 38.7 (IQR 31.2-46.8) mm at preintervention, intervention baseline, and postintervention, respectively. Multivariable generalized estimating equation analysis showed that both total plaque and noncalcified plaque indices at preintervention were significantly lowered as compared with intervention baseline levels; both total plaque and noncalcified plaque indices after intervention were significantly lowered as compared with intervention baseline levels; and reduced cocaine use was independently associated with lower total plaque volume index (P < 0.0001) and noncalcified plaque volume index (P = 0.010). CONCLUSIONS Our findings suggest that continued cocaine use may be associated with noncalcified plaque progression, whereas reduced cocaine use may be associated with noncalcified plaque regression. Larger studies are needed to confirm these findings.
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Affiliation(s)
- Veit Sandfort
- Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bldg 10/1C355, Bethesda, MD 20892, USA
| | - David A Bluemke
- Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bldg 10/1C355, Bethesda, MD 20892, USA
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jose Vargas
- Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bldg 10/1C355, Bethesda, MD 20892, USA
- MedStar Health Research Institute, Georgetown University Hospital, Washington, DC, USA
| | - Jeffrey A. Brinker
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Gary Gerstenblith
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Thomas Kickler
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Gang Zheng
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ji Li
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Shaoguang Chen
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Hong Lai
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Elliot K. Fishman
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Shenghan Lai
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA
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7
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Jordan CD, Korley FK, Stolbach AI. Self-reported cocaine use is not associated with elevations in high-sensitivity troponin I. Clin Toxicol (Phila) 2017; 55:332-337. [PMID: 28421838 DOI: 10.1080/15563650.2017.1285404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE High-sensitivity troponin (hsTn) assays detect 10 times lower concentrations of cardiac troponin than conventional assays. We examined the effects of self-reported cocaine use to determine whether those with acute cocaine use being evaluated for ACS are more likely to have elevated hsTnI than those nonusers being evaluated for ACS. METHODS We conducted a sub-analysis of a prospective cohort of ED patients evaluated for acute coronary syndrome. Recent cocaine use was determined by structured patient interviews. High-sensitivity troponin (Abbott) and conventional troponin I (Abbott, cTnI) were measured on samples drawn at presentation. Urine toxicology screen for cocaine metabolite was obtained at the discretion of treating clinicians. RESULTS Of 1862 patients enrolled, 444 reported prior cocaine use and 99 reported cocaine use within the preceding month. Median hsTn in patients with last cocaine use within 24 h, 2-7 days, 1 week-1 month, >1 month, and no prior cocaine use were: 9 (IQR: 3-17) ng/L, 6 (IQR: 3-24.3) ng/L, 6 (IQR: 3-89.5) ng/L, 3 (IQR: 3-18.5) ng/L and 3 (IQR: 3-17) ng/L, respectively. Urine toxicology assays (UTox) for cocaine were performed in 640 (34.4%) patients. The median hsTn for those who were UTox+, UTox - and those without a UTox were: 9 ng/L (IQR: 3-48.5), 9 ng/L (IQR: 3-40) and 3 ng/L (IQR: 3-12), respectively. There were no differences in the prevalence of new troponin elevations (hsTn >99th percentile but cTnI <99th percentile) in those with recent cocaine use compared to those without recent cocaine use. CONCLUSIONS In this first investigation of hsTn in patients with self-reported recent cocaine use, we have determined that hsTn does not lead to an increase in the prevalence of troponin elevation in cocaine users.
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Affiliation(s)
- Candice D Jordan
- a Department of Emergency Medicine , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Frederick K Korley
- b Department of Emergency Medicine , University of Michigan Medical School , Ann Arbor , MI , USA
| | - Andrew I Stolbach
- a Department of Emergency Medicine , Johns Hopkins University School of Medicine , Baltimore , MD , USA
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Guirgis FW, Gray-Eurom K, Mayfield TL, Imbt DM, Kalynych CJ, Kraemer DF, Godwin SA. Impact of an abbreviated cardiac enzyme protocol to aid rapid discharge of patients with cocaine-associated chest pain in the clinical decision unit. West J Emerg Med 2015; 15:180-3. [PMID: 24672608 PMCID: PMC3966447 DOI: 10.5811/westjem.2013.11.19232] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 11/05/2013] [Accepted: 11/22/2013] [Indexed: 11/18/2022] Open
Abstract
Introduction In 2007 there were 64,000 visits to the emergency department (ED) for possible myocardial infarction (MI) related to cocaine use. Prior studies have demonstrated that low- to intermediate-risk patients with cocaine-associated chest pain can be safely discharged after 9–12 hours of observation. The goal of this study was to determine the safety of an 8-hour protocol for ruling out MI in patients who presented with cocaine-associated chest pain. Methods We conducted a retrospective review of patients treated with an 8-hour cocaine chest pain protocol between May 1, 2011 and November 30, 2012 who were sent to the clinical decision unit (CDU) for observation. The protocol included serial cardiac biomarker testing with Troponin-T, CK-MB (including delta CK-MB), and total CK at 0, 2, 4, and 8 hours after presentation with cardiac monitoring for the observation period. Patients were followed up for adverse cardiac events or death within 30 days of discharge. Results There were 111 admissions to the CDU for cocaine chest pain during the study period. One patient had a delta CK-MB of 1.6 ng/ml, but had negative Troponin-T at all time points. No patient had a positive Troponin-T or CK-MB at 0, 2, 4 or 8 hours, and there were no MIs or deaths within 30 days of discharge. Most patients were discharged home (103) and there were 8 inpatient admissions from the CDU. Of the admitted patients, 2 had additional stress tests that were negative, 1 had additional cardiac biomarkers that were negative, and all 8 patients were discharged home. The estimated risk of missing MI using our protocol is, with 99% confidence, less than 5.1% and with 95% confidence, less than 3.6% (99% CI, 0–5.1%; 95% CI, 0–3.6%). Conclusion Application of an abbreviated cardiac enzyme protocol resulted in the safe and rapid discharge of patients presenting to the ED with cocaine-associated chest pain.
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Affiliation(s)
- Faheem W Guirgis
- University of Florida, Department of Emergency Medicine, Jacksonville, Florida
| | - Kelly Gray-Eurom
- University of Florida, Department of Emergency Medicine, Jacksonville, Florida
| | - Teri L Mayfield
- University of Florida, Department of Emergency Medicine, Jacksonville, Florida
| | - David M Imbt
- University of Florida, Department of Emergency Medicine, Jacksonville, Florida
| | - Colleen J Kalynych
- University of Florida, Department of Emergency Medicine, Jacksonville, Florida
| | - Dale F Kraemer
- University of Florida College of Medicine, Jacksonville; Center for Health Equity and Quality Research
| | - Steven A Godwin
- University of Florida, Department of Emergency Medicine, Jacksonville, Florida
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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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Abstract
OBJECTIVES Acute chest pain and myocardial infarction are frequent complications of cocaine use. Indeed, these represent 40% of emergency department visits associated with cocaine use and 2% to 7% of all patients attending the emergency department for chest pain. Nevertheless, the prevalence of past cocaine-associated chest pain has never been evaluated in an outpatient facility for addiction. Our objective was to assess lifetime episodes of cocaine-associated chest pain in current cocaine users in an outpatient facility. METHODS Fifty consecutive, nonselected current cocaine users were retrospectively evaluated with a standardized interview and a medical assessment. The patients and the pain characteristics are described, and clinical and biological factors associated with experiencing cocaine-associated chest pain are studied with univariate and logistic regressions analyses. RESULTS Twenty-six subjects (52%) reported a history of chest pain associated with cocaine use. This pain was frequently described as oppressive (28%) and located in the retrosternal area (61.5%). The mean (±SD) time between cocaine use and the occurrence of the pain was 8 (±8) minutes and the mean duration was 22 (±236) minutes. Subjects who reported cocaine-associated chest pain reported an average of 12 (±7) distinct episodes. Patients describing chest pain could be predicted with one independent factor in our sample: age of onset of cocaine use (P = 0.042). CONCLUSIONS Transient cocaine-associated chest pains are frequent in current cocaine users attending specialized addiction facilities. Cardiological explorations and monitoring and risk-reduction interventions need to be provided to this specific population.
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Hamilton B, Kwakyi E, Koyfman A, Foran M. Diagnosis and management of acute coronary syndrome. Afr J Emerg Med 2013. [DOI: 10.1016/j.afjem.2012.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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12
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Atherosclerotic plaque burden in cocaine users with acute chest pain: Analysis by coronary computed tomography angiography. Atherosclerosis 2013; 229:443-8. [DOI: 10.1016/j.atherosclerosis.2013.05.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 04/19/2013] [Accepted: 05/30/2013] [Indexed: 11/22/2022]
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Navarro Valverde C, Núñez Gil I, Fernández Ortiz A. Síndrome coronario agudo y coronariografía sin lesiones significativas: ¿lo sabemos todo? Med Clin (Barc) 2013. [DOI: 10.1016/j.medcli.2012.09.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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O'Conor K, Chang AM, Wu AHB, Hollander JE. Myeloperoxidase and C-reactive protein in patients with cocaine-associated chest pain. Am J Emerg Med 2013; 31:664-9. [PMID: 23380098 DOI: 10.1016/j.ajem.2012.11.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 10/31/2012] [Accepted: 11/23/2012] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Myeloperoxidase (MPO) and C-reactive protein (CRP) are markers of inflammation and elevated levels have been found in patients with acute coronary syndrome (ACS) unrelated to cocaine. We evaluated the utility of MPO and CRP for diagnosis of ACS and the prediction of 30-day adverse cardiovascular events in patients with cocaine-related chest pain. METHODS This is a secondary analysis from a prospective cohort study of ED patients who received evaluation for ACS. Structured data collection at presentation included demographics, chest pain history, laboratory results, and electrocardiographic data. Our primary outcome was diagnosis of ACS at index visit and 30-day adverse events. As a secondary analysis, we provide data on a matched cohort without cocaine use. RESULTS Baseline data and CRP were available for 95 cocaine users; 82 had MPO data also. Patients had a mean age of 46.6 (SD 8.1) years, 90% were black, and 62% were male. Acute coronary syndrome occurred in 7% of cocaine users. With respect to diagnosis of ACS, the area under the curve was poor for both MPO (0.65; 95% confidence interval [CI]: 0.40-0.91) and CRP (0.63; 95% CI: 0.39-0.88). Similar results were found for 30-day events. With respect to prognosis of 30-day adverse cardiovascular events, the area under the curve was 0.68 (95% CI: 0.45-0.91) for MPO and 0.67 (95% CI: 0.45-0.90) for CRP. Similar results were found for 30-day events. In the matched cohort of patients who were not cocaine users, performance of MPO (n = 66) and CRP (n = 86) was also poor. CONCLUSIONS Myeloperoxidase and CRP are not useful for diagnosis or prognosis of patients with cocaine-associated chest pain.
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Affiliation(s)
- Katie O'Conor
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Hendel RC, Ruthazer R, Chaparro S, Martinez C, Selker HP, Beshansky JR, Udelson JE. Cocaine-using patients with a normal or nondiagnostic electrocardiogram: single-photon emission computed tomography myocardial perfusion imaging and outcome. Clin Cardiol 2012; 35:354-8. [PMID: 22362335 DOI: 10.1002/clc.21977] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Revised: 01/26/2012] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Few trials have examined the outcomes of patients who use cocaine with chest pain and who have a normal or nondiagnostic electrocardiogram (ECG) and the use of single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI). HYPOTHESIS We sought to compare the characteristics and overall outcomes in cocaine users vs non-cocaine users presenting to the emergency department with a normal/nondiagnostic ECG and to assess the value of rest MPI in both of these populations. METHODS Patients with symptoms compatible with myocardial ischemia, suspected acute coronary syndrome (ACS), and a normal/nondiagnostic ECG were enrolled in the Emergency Room Assessment of Sestamibi for Evaluation of Chest Pain (ERASE Chest Pain) trial, a randomized controlled trial designed to evaluate the impact of rest MPI on triage decisions. Cocaine users (n = 294) were compared to non-cocaine users (n = 2180). Cocaine users were younger than non-cocaine users, and 72% were male. RESULTS Among the cocaine users, 2.4% had a myocardial infarction, 1.4% required percutaneous coronary intervention, and none of the patients underwent coronary artery bypass graft surgery. Among cocaine users with a final diagnosis of not ACS, randomization of patients to rest SPECT MPI resulted in an appropriate reduction in hospital admissions in both the cocaine users (P = 0.011) and the non-cocaine users (P < 0.001), suggesting improved triage when MPI was used. CONCLUSIONS Cocaine users with a normal/nondiagnostic ECG are at low risk of cardiac events. Even though cocaine users are at low risk of cardiac events, SPECT MPI remains effective in the risk stratification and improves triage management decisions resulting in lower admission rates and more discharges to home.
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Affiliation(s)
- Robert C Hendel
- Division of Cardiovascular Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA.
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Egan DJ, Pare JR. Clinical pathologic conference: A 65-year-old male with left-sided chest pain. A case of an unexpected occupational hazard. Acad Emerg Med 2012; 19:e1-6. [PMID: 22320376 DOI: 10.1111/j.1553-2712.2011.01269.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The authors present a case of a 65-year-old male who presented four times to the emergency department (ED) with left-sided chest pain. On the first three visits, the patient was admitted with a different diagnosis related to his chest pain. On the final visit, an abnormality on an imaging study performed in the ED led to the ultimate diagnostic test revealing the cause of the patient's symptoms. The patient's clinical presentation and ultimate clinical course are summarized, and a discussion of the differential diagnoses of his condition is presented.
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Affiliation(s)
- Daniel J Egan
- Department of Emergency Medicine, St. Luke's Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, NY, USA.
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Gharib AM, Abd-Elmoniem KZ, Pettigrew RI, Hadigan C. Noninvasive coronary imaging for atherosclerosis in human immunodeficiency virus infection. Curr Probl Diagn Radiol 2011; 40:262-7. [PMID: 21939819 PMCID: PMC3181085 DOI: 10.1067/j.cpradiol.2011.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Coronary artery disease is increasingly recognized as an important contributor to morbidity and mortality among persons living with human immunodeficiency virus (HIV) infection. Traditional cardiovascular disease risk factors as well as aspects of HIV infection and its therapy contribute to the increased coronary artery disease observed in HIV. Advances in noninvasive imaging methodologies in both computed tomography and magnetic resonance imaging provide opportunities to evaluate coronary artery atherosclerosis in ways not possible by conventional invasive x-ray angiography. Application of these techniques may prove very useful in the study of atherosclerosis in many diseases, such as HIV.
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Affiliation(s)
- Ahmed M Gharib
- Biomedical and Metabolic Imaging Branch, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD.
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Livshits Z, Hoffman RS. CTA and cocaine-associated chest pain: more evidence is needed. Acad Emerg Med 2011; 18:771; author reply 772-3. [PMID: 21729190 DOI: 10.1111/j.1553-2712.2011.01107.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hollander JE, Chang AM. CTA and Cocaine-associated Chest Pain. Acad Emerg Med 2011. [DOI: 10.1111/j.1553-2712.2011.01106.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Gao T, Shiwaku K, Fukushima T, Isobe A, Yamane Y. Medical education in China for the 21st century. MEDICAL EDUCATION 1999; 33:768-773. [PMID: 10583771 DOI: 10.1046/j.1365-2923.1999.00313.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Drastic changes are occurring in medical education around the world. Medicine and medical technologies are developing rapidly and expanding beyond the multidisciplinary area. The needs of medical care and medical education are different even from those of several years ago. In order to cope with these increasing social needs, the innovation of medical education in China has become an urgent and important problem. This study is an attempt to answer the question of how to develop medical education in China for the 21st century, based on a historical review of the development of medical education. This development might be divided into three periods: (1) before the Cultural Revolution; (2) the Cultural Revolution (1966-76); and (3) post-Cultural Revolution (1977-present) in modern China, and based on problem analysis of the curriculum, teaching methods, education evaluation, systems and policies and the balance between educational needs and supplies. We concentrate on the discussion of how to solve these problems, and have designed a new strategy for the further development of medical education in China. This discussion and newly developing strategy focuses on the main targets and priorities and adoption of suitable measures according to the conditions of the country. The purposes are to elevate the quality of medical education, to train qualified doctors to meet continuously increasing needs and to maintain the development of medical education for the 21st century in China.
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Affiliation(s)
- T Gao
- Department of Environmental Medicine, Shimane Medical University, Japan; Department of Medical Education, Health Bureau of Liaoning Province, China
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