Cocaine and the heart

Cardiovascular Risks of Simultaneous Use of Alcohol and Cocaine-A Systematic Review

Background: The simultaneous use of cocaine and alcohol is highly prevalent and is associated with high numbers of emergency department admissions, primarily due to cardiovascular complications. Aims: To answer the question of whether the co-use of cocaine and alcohol increases the cardiovascular risk compared to the use of cocaine alone. Method: A systematic review of human studies comparing the cardiovascular risk of co-used cocaine and alcohol with the use of cocaine alone. Results: Despite a higher myocardial workload induced by the co-use of cocaine and alcohol and the potentiation of cocaine's cardiovascular effects by alcohol, the findings on the risk and severity of cardiovascular symptoms due to combined use are inconsistent. However, the co-use of cocaine and alcohol clearly leads to higher mortality. Interestingly, the presence of cocaethylene, a unique metabolite generated only via a pharmacokinetic interaction between alcohol and cocaine, carries an 18- to 25-fold increase over the absence of cocaethylene (cocaine-alone users) in the risk of sudden death and is associated with myocardial injury and cardiac arrest, probably due to the inhibition of cardiac ion channels by cocaethylene. Conclusion: Despite the inconsistency in some of the results, it is concluded that the co-use of cocaine and alcohol poses an additional risk of cardiovascular fatalities compared to the use of cocaine alone.

Non-ST Segment Elevation Myocardial Infarction Associated With Cocaine Use

We present the case of a 23-year-old male with no significant past medical history who experienced acute chest pain. A diagnostic workup revealed that the patient had a non-ST-segment elevation myocardial infarction. Although the patient was not forthcoming initially with his cocaine use, he did admit it later in his emergency department course. The timing of his rise and fall of troponin is presented. The pathophysiology of cocaine-related chest pain and infarction is discussed. The patient continued to make an uneventful recovery.

Stimulant Drugs of Abuse and Cardiac Arrhythmias

Nonmedical use of prescription and nonprescription drugs is a worldwide epidemic, rapidly growing in magnitude with deaths because of overdose and chronic use. A vast majority of these drugs are stimulants that have various effects on the cardiovascular system including the cardiac rhythm. Drugs, like cocaine and methamphetamine, have measured effects on the conduction system and through several direct and indirect pathways, utilizing multiple second messenger systems, change the structural and electrical substrate of the heart, thereby promoting cardiac dysrhythmias. Substituted amphetamines and cocaine affect the expression and activation kinetics of multiple ion channels and calcium signaling proteins resulting in EKG changes, and atrial and ventricular brady and tachyarrhythmias. Preexisting conditions cause substrate changes in the heart, which decrease the threshold for such drug-induced cardiac arrhythmias. The treatment of cardiac arrhythmias in patients who take drugs of abuse may be specialized and will require an understanding of the unique underlying mechanisms and necessitates a multidisciplinary approach. The use of primary or secondary prevention defibrillators in drug abusers with chronic systolic heart failure is both sensitive and controversial. This review provides a broad overview of cardiac arrhythmias associated with stimulant substance abuse and their management.

Prevalence of myocardial infarction among patients with chest pain and cocaine use: A systematic review and meta-analysis

BACKGROUND

Cocaine abuse is a public health burden. Cocaine is known to cause vasospasm and acute myocardial infarction (AMI). The prevalence of AMI in patients presenting with chest pain and concurrent cocaine use (CPCC) varies among studies. We performed a systemic review and meta-analysis to assess the current literature for the prevalence of AMI in patients with CPCC.

METHODS

We performed a literature search of PubMed, EMBASE, and Scopus from its beginning to May 18, 2020 and updated this search on February 18, 2021. Full-text studies that assessed the primary outcome (AMI) specifically among patients with CPCC who presented to the emergency department (ED) were included. We excluded studies that were not in English, did not take place in the ED, and case reports, which only reported positive cases and not incidence of AMI. Random effect meta-analysis was performed to assess the prevalence of primary outcome and to examine correlations between risk factors and AMI. Heterogeneity was assessed by I-square value. We also performed subgroup analysis to identify potential sources of heterogeneity.

RESULTS

We identified 2178 studies and screened 102 full-text studies to include 16 studies (3269 patients) in our final analysis. The pooled prevalence of AMI was 4.7% (95% CI 0.8-23), I-square of 84%. However, rates among studies of low risk patients were lower (1.1% 95% CI 0.2-5) compared to studies of mixed risk patients (7.7%, 95% 5-11). A meta-regression was used to look at correlation between risk factors and AMI and found that AMI was positively correlated in patients with a history of CAD (correlation coefficient [Corr. Coeff.] 5.6, 96% CI 2.3-8.7), HTN (Corr. Coeff. 2.9, 95% CI 0.9-4.9), DM (Corr. Coeff. 8.0, 95% CI 2.4-14), HLD (Corr. Coeff. 5.9, 95% CI 2.4, 9). Sources of potential heterogeneity included patients' risk as defined by the authors, study designs, publication year, and study sample size.

CONCLUSION

The overall prevalence of AMI and death among patients with cocaine-associated chest pain was relatively low, although high risk patients were still associated with high prevalence of AMI. Clinicians should consider risk-stratify these patients and treat them accordingly.

Cocaine use and overdose mortality in the United States: Evidence from two national data sources, 2002-2018

BACKGROUND

Cocaine-involved overdose mortality has recently risen in the United States (US), yet it is unclear to what extent patterns in cocaine-involved overdose mortality parallel patterns in cocaine use. This study: examined time trends (2002-2018) in past-year cocaine use and cocaine-involved overdose mortality in the US; and compared demographics and drug involvement of adults who reported past-year cocaine use versus adults who died of a cocaine-involved overdose.

METHODS

Data from two sources were utilized: (1) the National Survey on Drug Use and Health (n = 1,334 adults self-reporting cocaine use in 2018); and (2) the Multiple Cause of Death dataset of the National Center for Health Statistics (N = 14,630 adults who died of a cocaine-involved overdose in 2018). The study examined prevalence of past-year cocaine use, mortality rates for cocaine-involved overdose, 2002-2018 trends, demographic characteristics, and involvement of other drugs.

RESULTS

Results of Joinpoint Regression indicated that the prevalence of past-year cocaine use increased after 2011, with an annual percent change of 5.13, while age-adjusted cocaine-involved overdose mortality rates escalated after 2012, with an annual percent change of 26.54. In 2018, prevalence of past-year cocaine use did not significantly differ (p = 0.09) by racial/ethnic group, yet Non-Hispanic Blacks had an age-adjusted cocaine-involved overdose mortality rate more than double the rate in Non-Hispanic Whites and significantly higher (p < 0.001) than in any other group.

CONCLUSIONS

While the prevalence of cocaine use has increased modestly, cocaine-involved overdose mortality has risen dramatically. Cocaine-involved overdose mortality is disproportionately affecting individuals who are Black, older, or with lower educational attainment.

Transient Left Ventricular Acute Failure after Cocaine Use

BACKGROUND

Cocaine is one of the most widely used illicit drugs, and it is the most common cause of drug-related death. The association of cocaine use with acute heart failure is a rare occurrence.

CASE REPORT

We report the case of a 31 years-old woman who presented Takotsubo cardiomyopathy with severe cardiogenic shock after cocaine abuse. That required the use of high doses of positive inotropic amines and mechanical ventilation. The evolution was quickly favorable after the cessation of cocaine.

DISCUSSION

Takotsubo cardiomyopathy is often related to a stressful trigger, and several cases have been described with the use of several psychostimulants. As such, it is not surprising that cocaine use can be associated with the development of Takotsubo cardiomyopathy when it results in excess release of catecholamines and excitation of adrenergic receptors.

CONCLUSION

In critical care unit, Takotsubo cardiomyopathy is a rare complication of cocaine abuse. This etiological diagnosis can be difficult especially in the absence of the concept of toxic intake as it was initially the case for our patient, but the treatment does not differ from other causes of cardiomyopathy and Cessation of cocaine use has been associated with improvement in cardiac function.

Marijuana-induced Coronary Vasospasm and Myocardial Infarction: A Case Report and Review of Literature

The usage of marijuana and its legalization has been growing rapidly, being abused by a wide range of age groups. Its effects on the heart are well known, but coronary artery vasospasm causing ST elevation myocardial infarction (STEMI) from Marijuana alone is rather lesser known. Herein, we report a case of a middle aged African American man with a significant tobacco smoking history who presented with chest pain typical of myocardial infarction (MI) soon after smoking marijuana. ECG showed ST elevation in inferior leads with first degree AV block and a urine drug screen positive only for marijuana. Coronary angiogram showed mid right coronary artery (RCA) obstruction which was relieved upon injection of intracoronary nitroglycerine. This case report reinstates the significance of considering substance abuse as an etiology of STEMI during initial presentation, ruling out with urine drug samples. We also present a literature review of coronary vasospasm with STEMI, induced specifically by Marijuana and its pathophysiologic mechanisms.

Cocaine Abuse: An Attack to the Cardiovascular System-Insights from Cardiovascular MRI

Cocaine is the most commonly used illicit drug in the European Union. Its cardiac effects are numerous and diverse, both in acute and chronic abuse, and include myocardial infarction, myocarditis, catecholamine-induced cardiomyopathy, and chronic cardiomyopathy (subclinical, hypertrophic, and dilated phases). Their clinical manifestations are vastly overlapping, and differential diagnosis should be performed using a thorough diagnostic workup featuring clinical history, laboratory tests, electrocardiography, stress test, noninvasive imaging modalities, and coronary angiography. Cardiac MRI has the unique ability of in vivo tissue characterization. This unique feature can play a pivotal role in the differential diagnosis through proper characterization of the myocardial tissue. Especially in acute settings, cardiac MRI makes it possible to distinguish between cocaine-induced myocardial infarction, cocaine-induced myocarditis, and catecholamine-induced cardiomyopathy. Conversely, in chronic cardiomyopathy, cardiac MRI permits evaluation of ventricular function and myocardial tissue, allowing the investigation of the underlying cause. On the one hand, assessing the ventricular function permits differentiation among subclinical, hypertrophic, and dilated phases of chronic cardiomyopathy; on the other hand, cardiac MRI could classify the causes underlying remodeling, including chronic ischemic injury, chronic myocarditis, and cardiac motion impairment. This review analyzes the relationship between pathophysiology, histology, and disease using the existing literature on cardiac MRI cocaine abuse evaluation. © RSNA, 2019.

Acute and Chronic Effects of Cocaine on Cardiovascular Health

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.

Histologic Changes In Recreational Drug Misuse

Use of recreational drugs is associated with a number of histologic changes. These may be related to the method of administration or due to systemic effects of the drugs. This paper reviews the histopathological features seen following recreational drug use. With injection, there may be local effects from abscess formation and systemic effects may result in amyloidosis. Injections have been associated with necrotizing fasciitis, anthrax, and clostridial infections. Systemic effects include infective endocarditis, with the risk of embolization, and abscesses may be seen in organs in the absence of infective endocarditis. Viral complications of injection include hepatitis and human immunodeficiency virus (HIV) infection. Injecting crushed tablets can result in intravascular granulomata in the lungs. Smoking drugs is associated with intraalveolar changes, including blackand brown-pigmented macrophages in crack cocaine and cannabis smoking, respectively. Snorting may result in intraalveolar granulomata forming when crush tablets are used and there may be systemic granulomata. Stimulants are associated with cardiovascular and cerebrovascular pathology, including contraction band necrosis and myocardial fibrosis, as well as coronary artery dissection. Stimulants may cause hyperpyrexia and rhabdomyolysis, which may be associated with changes in multiple organs including myoglobin casts in the kidney. Opioids cause respiratory depression and this can be associated with inhalational pneumonia and hypoxia in other organs if there is resuscitation and a period of survival. Ketamine use has been associated with changes in the urothelium and the liver. This paper reviews histology changes that may be seen in drug-related deaths using illustrative cases.

Doping in sport and exercise: anabolic, ergogenic, health and clinical issues

The use of doping agents is evident within competitive sport in senior and junior age groups, where they are taken by non-elite as well as elite participants. They are also taken in non-sporting contexts by individuals seeking to ‘improve’ their physique through an increase in muscle and/or decrease in fat mass. While attaining accurate data on the prevalence of their use has limitations, studies suggest the illicit use of doping agents by athletes and non-athletes may be 1–5% in the population and greater than 50% in some groups; with the prevalence being higher in males. There is conclusive evidence that some doping agents are anabolic and ergogenic. There is also evidence that the use of doping agents such as anabolic androgenic steroids, growth hormone and other anabolic agents, erythropoietin and stimulants conveys considerable health risks that include, but are not limited to: cardiovascular disease, diabetes, cancer, mental health issues, virilisation in females and the suppression of naturally produced androgens in males. This review will outline the anabolic, ergogenic and health impacts of selected doping agents and methods that may be used in both the sporting and physique development contexts. It also provides a brief tabulated overview of the history of doping and how doping agents may impact upon the analyses of clinical samples.

Assessing marijuana use in bariatric surgery candidates: should it be a contraindication?

Research has demonstrated negative effects of both alcohol and tobacco use after bariatric surgery. However, no research to date has examined effects of cannabis use after bariatric surgery, even though cannabis is the most commonly used illicit drug in the USA. Literature review reveals that many practitioners generalize from data regarding alcohol abuse to all substances. Further, many screening protocols fail to differentiate between varying levels of cannabis use. The current report aims to (1) review the relevant literature on marijuana use and its potential consequences among bariatric patients, (2) discuss relevant problems and gaps in this literature, and (3) make preliminary recommendations regarding the assessment and treatment planning of bariatric candidates who disclose marijuana use.

Vascular effects of diphenylmethoxypiperidine-derived dopamine uptake inhibitors

Vascular effects of 4-aryl methoxypiperidinol compounds previously shown to share with cocaine the ability to inhibit the dopamine transporter are described. All the compounds tested inhibit KCl-induced and noradrenaline-dependent contractions in mesenteric arteries ex vivo. Thus, diphenylpyraline and its analogs may have a role as therapeutic options for the treatment of some of the cardiotoxic effects of cocaine intoxications.

Identifying Drug (Cocaine) Intake Events from Acute Physiological Response in the Presence of Free-living Physical Activity

A variety of health and behavioral states can potentially be inferred from physiological measurements that can now be collected in the natural free-living environment. The major challenge, however, is to develop computational models for automated detection of health events that can work reliably in the natural field environment. In this paper, we develop a physiologically-informed model to automatically detect drug (cocaine) use events in the free-living environment of participants from their electrocardiogram (ECG) measurements. The key to reliably detecting drug use events in the field is to incorporate the knowledge of autonomic nervous system (ANS) behavior in the model development so as to decompose the activation effect of cocaine from the natural recovery behavior of the parasympathetic nervous system (after an episode of physical activity). We collect 89 days of data from 9 active drug users in two residential lab environments and 922 days of data from 42 active drug users in the field environment, for a total of 11,283 hours. We develop a model that tracks the natural recovery by the parasympathetic nervous system and then estimates the dampening caused to the recovery by the activation of the sympathetic nervous system due to cocaine. We develop efficient methods to screen and clean the ECG time series data and extract candidate windows to assess for potential drug use. We then apply our model on the recovery segments from these windows. Our model achieves 100% true positive rate while keeping the false positive rate to 0.87/day over (9+ hours/day of) lab data and to 1.13/day over (11+ hours/day of) field data.

Pulmonary embolism in a patient receiving risperidone and paliperidone: A case report and review of the literature

Several cases of pulmonary embolism (PE) have been associated with antipsychotic treatment. We report a case of an otherwise healthy 27-year old male who developed a PE after receiving paliperidone long acting injection. The patient received risperidone long acting injection for over 3 months before initiating paliperidone, but was switched incorrectly. After 3 weeks on paliperidone long acting injection the patient developed a PE requiring hospitalization and a course of anticoagulation. A review of atypical antipsychotic-induced venous thromboembolism is discussed.

The maternal, fetal, and neonatal effects of cocaine exposure in pregnancy

Despite multiple efforts to reduce the use of illicit drugs, the epidemic of addiction continues to be a significant public health issue. Through its easy availability, the number of people afflicted with this addiction continues to rise, including women of childbearing age. Secondarily, any health care crisis that occurs in this age group of women will have potential implications in pregnancy, infancy, and childhood. The use of cocaine alone or in conjunction with other illicit drugs, combined with the normal physiological cardiovascular changes in pregnancy, leads to a myriad of pathophysiological changes, thereby placing the life of the pregnant cocaine user, as well as the health status of their unborn fetus and neonate at risk for adverse outcomes. As more data are available, the long-term physical, mental, and developmental sequelae for children exposed to cocaine in utero prove that this public health crisis has serious implications. The pregnancy-specific maternal, fetal, and neonatal risks of cocaine use during the antepartum period are reviewed.

Cocaine-related health emergencies in Europe: a review of sources of information, trends and implications for service development

BACKGROUND

Cocaine-related health consequences are difficult to observe. Data on drug users in health-emergency settings may be a useful source of information on consequences that are not visible via other information sources.

METHODS

Thirty European countries submit an annual national report on the drug situation to the EMCDDA. All reports for the period 2007-2010 were analyzed, with particular attention given to auditing cocaine-related mentions. Analysis was also performed in order to identify sources and case definitions, assess coverage, audit cases and, where possible, to identify long-term trends.

RESULTS

Considerable heterogeneity existed between countries in their approach to recording drug-related emergencies, with only Spain and the Netherlands having established formal indicators. The highest annual numbers of cocaine-related episodes were reported by the UK (3,502), Spain (2,845) and the Netherlands (1,211). A considerable (2- to 3-fold) increase in the numbers of cocaine-related episodes has been reported since the end of the 1990s in these countries; these increases peaked in Spain and England around 2007/08.

CONCLUSIONS

The analysis reported here suggests the need to develop more standardized approaches to monitoring drug-related emergencies. It points to the potential value of developing effective referral links between the emergency and specialized drug services working with cocaine users.

A cost-effectiveness analysis of modafinil therapy for psychostimulant dependence

INTRODUCTION AND AIMS

To examine the cost-effectiveness of modafinil (200 mg daily) plus counselling compared with placebo for the treatment of psychostimulant dependence.

DESIGN AND METHODS

Cost and outcome data were collected alongside two randomised controlled trials of modafinil 200 mg daily over 10 weeks for methamphetamine (n = 74) and cocaine dependence (n = 8), respectively. Incremental cost-effectiveness ratios representing the additional costs to achieve a given outcome were calculated for both the change in the number of stimulant-free days and quality-adjusted life years 12 weeks post-treatment.

RESULTS

The incremental cost-effectiveness ratio indicated that it would cost an additional $AUD79 to achieve an extra stimulant-free day with modafinil compared with placebo. This result was not statistically significant, but appeared to be a robust estimate after sensitivity analysis. Counselling, whether received within program or from other services, improved the cost-effectiveness of modafinil relative to placebo.

DISCUSSION AND CONCLUSIONS

Strategies to improve the uptake of counselling are recommended as cost-effective.

Pharmacokinetics of cocaine and metabolites in human oral fluid and correlation with plasma concentrations after controlled administration

Oral fluid is an attractive alternative matrix for drug testing with a noninvasive and directly observed collection, but there are few controlled cocaine administration studies to guide interpretation.

MATERIALS AND METHODS

While residing on a closed research unit for up to 10 weeks under constant medical supervision, 19 participants were administered 75 mg/70 kg subcutaneous cocaine and 14 received 150 mg/70 kg. The disposition of cocaine, benzoylecgonine (BE), and ecgonine methyl ester (EME) into oral fluid was determined by gas chromatography-mass spectrometry for 0.08 to 48 hours after administration.

RESULTS

In oral fluid collected by citric acid candy-stimulated expectoration, cocaine first appeared in oral fluid 0.08 to 0.32 hours after dosing and was rapidly eliminated with half-lives of 1.1 to 3.8 hours. BE and EME were first detected 0.08 to 1.0 hours after dosing with longer half-lives of 3.4 to 13.8 (BE) and 2.4 to 15.5 hours (EME) (P < 0.05). Oral fluid and plasma concentrations were significantly correlated for cocaine, BE, and EME (P < 0.0001). There were no significant differences (P > 0.05) in first and last detection times with the 8-μg/L cutoff proposed by the Substance Abuse and Mental Health Services Administration or the 10-μg/L cutoff from the European initiative, Driving Under the Influence of Drugs, Alcohol and Medicines. Metabolite:cocaine ratios increased after cocaine administration, potentially helpful for interpreting time of last use. Comparison of oral fluid collection through citric acid candy-stimulated expectoration, citric acid-treated Salivette, and neutral cotton Salivette devices did not reveal significant differences between devices for areas under the curve for cocaine, BE, or EME (P > 0.05).

DISCUSSION AND CONCLUSION

These results provide additional evidence for interpreting cocaine and metabolite concentrations in oral fluid and oral fluid's usefulness as an alternative matrix for drug testing.

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

AIMS

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

METHODS AND RESULTS

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

CONCLUSION

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

Effects of chronic exposure to crack cocaine on the respiratory tract of mice

Smoked cocaine (crack cocaine) causes several forms of injury to the respiratory tract, including asthma exacerbations, lung edema and hemorrhage, and nasal mucosal alterations. Few studies, however, have assessed respiratory tract pathology in habitual users of crack cocaine. Here, we describe the histological alterations in the respiratory tract of mice caused by chronic inhalation of crack cocaine. Twenty 2-month-old BALB/c mice were exposed to the smoke of 5 g crack cocaine in an inhalation chamber once a day for two months and compared to controls (n = 10). We then morphometrically analyzed nose and bronchiolar epithelial alterations, bronchiolar and alveolar macrophage cell density, alveolar hemosiderin content, and in addition determined the vasoconstriction index and the wall thickness of pulmonary arteries. The serum cocaine level was 212.5 ng/mL after a single inhalation. The mucus content of the nasal epithelium increased in crack-exposed animals, and the nasal and bronchial epithelium thickness decreased significantly. The alveolar hemosiderin content and the alveolar and bronchiolar macrophage cell density increased in animals exposed to crack. The vasoconstriction index increased in the pulmonary arteries of the exposed group. Chronic crack cocaine inhalation causes extensive histological changes along the entire respiratory tract.

Effects of cocaine esterase following its repeated administration with cocaine in mice

BACKGROUND

A bacterial cocaine esterase (CocE) produces robust protection and reversal of cocaine toxicity. The aim of this study was to investigate how effectiveness of CocE was changed following its repeated administration together with cocaine.

METHODS

Cocaine toxicity was quantified by measuring the occurrence of convulsions and lethality in mice. Immunologic responses of CocE were determined using ELISA. In the protection experiment, i.v. CocE 0.3mg was given 1min before a lethal dose of i.p. cocaine 180mg/kg. In the rescue experiment, i.v. CocE 0.3mg was given 1min after the occurrence of convulsions elicited by i.p. cocaine 100mg/kg. In both treatment paradigms, four trials were conducted in the same animals with a 2-week interval.

RESULTS

CocE retained its effectiveness to protect or rescue mice during the first two trials and these mice did not show an immune response. In contrast, CocE's effectiveness was gradually reduced in the last two trials, accompanied by 10- and 100-fold increases in anti-CocE antibody titers. Nevertheless, effectiveness of CocE could be partially recovered by increasing the dose of CocE. In addition, escalating the dose of CocE from the minimum effective dose for repeated administration could also retain CocE's effectiveness longer and slow the production of anti-CocE antibodies.

CONCLUSIONS

These results indicate that CocE is a weak antigen and it can maintain its protective and rescuing ability initially against cocaine-induced toxicity. Decreased effectiveness of CocE following repeated use can be partially improved by adjusting the dose and frequency of CocE treatment.

Cocaine: recent trends in Northern Ireland

A review of autopsy reports in cases in which cocaine featured in the cause of death in Northern Ireland revealed that there were 18 deaths between 1(st) January 1999 and 31(st) December 2007. Analysis revealed an increasing incidence of these deaths during the study period and this is compared to national statistics and those published by local drug addiction services and police.

Cocaine-induced midline destructive lesions mimicking ENT-limited Wegener's granulomatosis

The prevalence of cocaine use is rising worldwide, with a resultant rise in associated pathology. Regular nasal use can cause cocaine-induced midline destructive lesions (CIMDL), which can be difficult to distinguish from ear, nose, and throat (ENT)-limited Wegener's granulomatosis (WG). Two cocaine users presented with mid-facial pain, epistaxis, and systemic symptoms. Both had nasal septal perforation, necrosis of sinus mucosa, and positive anti-neutrophil cytoplasmic antibodies (ANCA). Histology was inconclusive and treatment with immunosuppressive drugs was commenced. The first patient continued to use cocaine initially, with improvement in her symptoms only on high doses of steroid. Later she stopped cocaine and this plus a switch from cyclophosphamide to mycophenolate mofetil resulted in successful symptom resolution and steroid withdrawal. The second patient denied cocaine use but having only partially responded to high-dose prednisolone and methotrexate, she admitted continued cocaine use and was lost to follow-up. Evaluation of a patient with destructive lesions of the mid-face should include enquiry about intranasal use of cocaine. Localized ENT involvement, inconsistent ANCA pattern, and atypical biopsy findings for WG should be recognized as features of CIMDL. Although cessation of cocaine use is crucial, there may be a role for immunosuppression.

Exercise stress testing in recently abstinent chronic cocaine abusers

We compared treadmill exercise stress testing (EST) in 28 medically screened, chronic cocaine users with the cardiovascular effects of an IV cocaine challenge (25 mg or 50 mg). All subjects had a clinically normal EST and echocardiography (except 2 subjects had septal wall hypokinesis). The EST produced significantly greater increases in heart rate and rate-pressure product than did the cocaine challenges. These findings suggest that EST may not provide additional diagnostic information in medically screened cocaine users. EST may cause more cardiac work (indicated by heart rate and blood pressure) than intravenous cocaine (at the doses in this study).

Troponin I in the intensive care unit setting: from the heart to the heart

When measured in the plasma, cardiac troponins T (cTnT) and I (cTnI) are considered to be highly specific markers of myocardial cell damage; however, research has demonstrated that troponin elevation may associated with causes other than coronary artery disease. In the intensive care unit (ICU) setting, increased cTnI levels are quite common findings and when documented, even on admission, intensivists should bear in mind that this laboratory finding holds a prognostic role independent of the reason for ICU admission. The mechanism(s) (such as demand ischemia, myocardial strain, etc.) and not simply the cause (i.e., renal failure) of the increment in serum cTnI should be investigated to better tailor the therapeutical regimen in the single patient. In this review, we therefore consider the nonthrombotic causes of troponin elevation in the critical setting.

Cocaine-related acute aortic dissection: patient demographics and clinical outcomes

BACKGROUND

To compare the demographics, inpatient mortality and short-term survival following hospital discharge between cocaine-using and non-cocaine-using patients presenting with acute aortic dissection.

METHODS

Retrospective analysis of 46 consecutive patients admitted with the diagnosis of acute aortic dissection at the Mount Sinai Hospital (Chicago, USA) between 1996 and 2005. Among these 46 patients, cocaine use was temporally related to the presenting symptom in 13 patients (28%, group 1). Patients who were not cocaine users were grouped into group 2 (33 patients [72%]).

RESULTS

Patients in group 1 were younger than those in group 2 (mean age 38+/-9 years versus 63+/-17 years, P=0.001), more likely to be smokers (13 of 13 patients [100%] versus 15 of 33 patients [45%], P=0.001) and had a higher prevalence of accelerated hypertension (mean blood pressure 210/130 mmHg) compared with group 2 (10 of 13 patients [77%] versus 11 of 33 patients [33%]) (P=0.01). Group 1 patients had a higher prevalence of type B dissection than group 2 (nine of 13 patients [69%] versus one of 33 patients [3%]). After hospital discharge, eight of 13 patients (62%) in the cocaine group continued to use cocaine. Mortality following hospital discharge was significantly higher in cocaine users (nine of 13 patients [69%]) compared with the non-cocaine users (four of 33 patients [12%], P=0.01). Recurrent dissection was the cause of death in five of the 13 deaths (42%) in the cocaine group.

CONCLUSIONS

Patients presenting with acute aortic dissection temporally related to cocaine use are more likely to be younger, smokers, have higher prevalence of hypertensive crises, more likely to have type B aortic dissection and may have a higher mortality following hospital discharge, possibly due to continued cocaine use and recurrent aortic dissection.

Cocaine-induced myocardial infarction

To date, cocaine-induced myocardial infarction (MI) remains an infrequent reason for admission into hospital. However, reports identify rising cocaine usage in the UK. With 7-10% of all patients presenting chest pain having traces of cocaine in their urine, there is an increasing incidence of cardiovascular disease in the under 30s age group. The potential impact on health care resources must cause concern. This report describes the case of a young man admitted to the emergency department after an 18-h cocaine session. With evidence of an anterolateral MI, left heart studies and thrombectomy were undertaken in cardiac catheters. Admission to critical care was required for ongoing respiratory and cardiac support therapies. Although there are many aspects of patient management that can be explored, specific issues to be discussed in this paper include evidence-based treatment options, nursing management of inotrope administration and caring for family and friends.

Lifetime major depression is associated with coronary heart disease in older adults: results from the National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVE

To examine the association between mood and anxiety disorders and coronary heart disease (CHD) in a nationally representative sample of older adults.

METHODS

Data from the National Epidemiologic Survey on Alcohol and Related Conditions were analyzed with 10,573 adults aged > or = 60 years surveyed.

RESULTS

A total of 13.30% of older adults reported diagnoses of CHD. Age (odds ratio (OR) = 1.04), morbid obesity (OR = 1.60), hypertension (OR = 2.29), lifetime nicotine dependence (OR = 1.41), and lifetime drug use disorders (OR = 2.19) were all significantly related to CHD. Being female (OR = 0.73) relative to male and a lifetime social drinker (OR = 0.71) compared with alcohol abstainers decreased the odds of CHD. After controlling for these characteristics, the presence of a lifetime major depressive episode was significantly associated with increased risk of CHD (OR = 2.05), but the lifetime anxiety disorders assessed were not. The association between lifetime mood disorders and CHD was similar for both genders, and single versus multiple depressive episodes conferred equal risk of CHD.

CONCLUSIONS

These data demonstrate that a lifetime major depressive episode increases the risk of CHD in older adults.

Cocaine, loin pain, and renal vein thrombosis

We report an unusual renal complication of cocaine abuse in a young man who developed loin pain, renal vein thrombosis, and acute renal failure. Cocaine abuse should be considered in the differential diagnosis of renal vein thrombosis in young adults.

Physical health, illicit drug use, and demographic characteristics in rural stimulant users

CONTEXT

There is growing concern about illicit rural stimulant use, especially regarding methamphetamine use and its health consequences.

PURPOSE

The present study describes associations between aspects of stimulant use and illness experience in rural areas, with additional focus on the role of demographic characteristics in these associations.

METHODS

The research participants were 710 stimulant drug users who were recruited from rural areas of Arkansas, Kentucky, and Ohio using Heckathorn's respondent-driven sampling method. Health was measured by self-reports of perceived health and extent of current, recent, and lifelong health problems. Drug use was measured with self-reports of type and frequency of use.

FINDINGS

Several associations were found between drug use and illness, controlling for demographics. Stimulant use pattern related significantly with the sum of health problems in the previous 6 months and the sum of lifetime illness diagnoses, after adjustment for demographic factors. Extent of illicit drug use in the past month and self-perceived drug and alcohol problems were associated with several measures of health.

CONCLUSIONS

In this sample of stimulant users, methamphetamine use was associated with fewer recent medical problems than crack cocaine, combined crack and powder cocaine use, and use of all 3 of these stimulants. These results, across the 3 sites, suggest that prevalent assumptions about the methamphetamine "plague" and its negative health consequences must be viewed cautiously and examined with additional research.

Chronic cocaine exposure in Drosophila: life, cell death and oogenesis

Developmental signaling cascades that can be perturbed by cocaine and other drugs of abuse have been difficult to study in humans and vertebrate models. Although numerous direct neural targets of cocaine have been elucidated at the molecular level, little is known about the specific cellular events that are impacted indirectly as a result of the drug's perturbation of neural circuits. We have developed oogenesis in Drosophila melanogaster as a model in which to identify downstream biochemical and/or cellular processes that are disrupted by chronic cocaine exposure. In this model, cocaine feeding resulted not only in expected reductions in viability, but also in unanticipated developmental defects during oogenesis, including aberrant follicle morphogenesis and vitellogenic follicle degeneration. To identify mechanisms through which cocaine exerted its deleterious effects on oogenesis, we examined candidate components of neural and hormonal signaling pathways. Cocaine-induced disruptions in follicle formation were enhanced by juvenile hormone exposure and phenocopied by serotonin feeding, while cocaine-activated follicle apoptosis was enhanced by concomitant dopamine feeding. HPLC analysis of dopamine and serotonin in the ovary suggests that these neurotransmitters could variably mediate cocaine's effects on oogenesis indirectly in the brain and/or directly in the ovary itself. We confirmed the involvement of hormone signaling by measuring ecdysteroids, which increase following cocaine exposure, and by demonstrating suppression of cocaine-induced follicle loss by hormone receptor mutants. Cocaine-induced ovarian follicle apoptosis and adult lethality appear to be caused by modulation of dopamine levels, while morphological defects during follicle formation likely result from perturbing serotonin signaling during cocaine exposure. Our work suggests not only a new role for juvenile hormone and/or serotonin in Drosophila ovarian follicle formation, but also a cocaine-sensitive role for dopamine in modulating hormone levels in the female fly.