Acute aortic dissection related to crack cocaine

The cardiovascular pathologist in the aortic team

Aortic diseases require a multidisciplinary management for diagnosis, treatment and follow-up with better outcomes in referral centers using a team-based approach. The setting up of a multi-disciplinary aortic team for the discussion of complex cases has been already proposed; it is also supported by the ACC/AHA. Surgeons and radiologists, more or less other physicians such as cardiologists, geneticists, rheumatologists/internal medicine specialists and pathologists are involved into such a team. The role of the cardiovascular pathologist is to examine the aortic specimens, to diagnose and classify the aortic lesions. Herein, the role of the pathologist in the aortic team is discussed and the pathobiology of aortic diseases is reviewed for reference by pathologists. The aortic specimens are mainly obtained from emergency or elective surgical procedures on the thoracic aorta, less frequently from organ/tissue (including cardiac or heart valve) donors, post-mortem procedures or abdominal aortic surgery. In the last decade, together with the progress of medical sciences, the histological definitions and classifications of the aortic pathology are undergoing thorough revisions that are addressed to an etiopathogenetic approach because of possible clinico-pathological correlations, therapeutic and prognostic impact. Pathologists may also have an important role in research and teaching. Therefore, histological analyses of the aortic specimens require adequate sample processing and pathologist expertise because histology contributes to definite diagnosis, correct management of patients and even (in genetic diseases) families, but also to research in the challenging field of aortopathies.

Diagnosing aortic dissection: A review of this elusive, lethal diagnosis

Aortic dissection (AD) remains a difficult diagnosis in the emergency setting. Despite its rare occurrence, it is a life-threatening pathology that, if missed, is typically fatal. Previous studies have documented minimal improvement in timely and accurate diagnoses despite the advancement of computed tomography. Previous literature has highlighted aortic dissections as a major cause of serious misdiagnosis-related harm. The aim of this article is to review the available literature on AD, discussing the diversity in presentations and the prevalence of historical and exam features to better aid in the diagnosis of AD. AD remains a difficult diagnosis, even with the widespread prevalence of computed tomography angiography usage. No single feature of the history or physical examination is enough to raise suspicion. The diagnosis should be strongly considered in any patient with chest pain that is severe and unexplained by other findings or testing. Those who do not present with acute pain are often complicated by neurologic deficits, hypotension, or syncope. These patients suffer from a change in mental status limiting their ability to participate in the history and physical examination and have a higher rate of complications and mortality. An educated understanding of the atypical presentations of aortic dissection helps the clinician to realistically rank it on the differential diagnosis, culminating in judicious use of definitive imaging.

[Recreative drug use and cardiovascular disease]

Widely spread, and continuously increasing, recreational drug use in general population has been associated with cardiovascular events, as illustrated by clinical studies and supported by a pathophysiological rationale. Understanding the cardiovascular effects of drugs, screening, and secondary prevention are crucial components in the management of those patients in cardiology.

An Uncommon Presentation of Acute Thoracic Aortic Dissection

We present a case of a 40-year-old Caucasian male with past medical history of polysubstance abuse (cocaine and methamphetamine), who presented to the emergency department (ED) complaining of intermittent cough with associated chest discomfort and shortness of breath for 2 weeks. Initial vital signs demonstrated borderline tachycardia (98 beats per minute), tachypnea (37 times per minutes), and hypoxia (oxygen saturation 89% on room air), and his physical exam was grossly unremarkable. A preliminary workup including a computed tomography angiography (CTA) revealed a type A aortic dissection with both thoracic and abdominal involvement for which the patient was admitted. This patient had resection of the ascending aorta with graft placement, cardiopulmonary bypass, aortic root replacement using composite prosthesis and left and right coronary reconstruction and reimplantation and survived a complicated hospital course. This case demonstrates the classic association known to exist between recreational drug use, specifically stimulants such as cocaine and amphetamines, and acute aortic dissection (AAD). However, such a presentation of borderline subacute, painless dissection in the setting of polysubstance use raises further questions, since uncommon AAD is typically found in higher-risk populations such as those with connective tissue disorders (Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome), bicuspid aortic valve, chronic hypertension, or previous aortic pathology. We therefore suggest clinicians strongly consider uncommon AAD as part of their differential diagnosis in patients with known or highly suspected polysubstance abuse.

Acute aortic syndromes: An internist's guide to the galaxy

Acute aortic syndromes (AASs) are severe conditions defined by dissection, hemorrhage, ulceration or rupture of the thoracic aorta. AASs share etiological and pathophysiological features, including long-term aortic tissue degeneration and mechanisms of acute aortic damage. The clinical signs and symptoms of AASs are unspecific and heterogeneous, requiring large differential diagnosis. When evaluating a patient with AAS-compatible symptoms, physicians need to integrate clinical probability assessment, bedside imaging techniques such as point-of-care ultrasound, and blood test results such as d-dimer. The natural history of AASs is dominated by engagement of ischemic, coagulative and inflammatory pathways at large, causing multiorgan damage. Medical treatment, multiorgan monitoring and outcome prognostication are therefore paramount, with internal medicine playing a key role in non-surgical management of AASs.

Early Onset Cardiovascular Disease from Cocaine, Amphetamines, Alcohol, and Marijuana

Cardiovascular disease (CVD), a disease typically associated with aging and the definitive leading cause of death worldwide, now threatens the young and middle-aged populations. Recreational abuse of alcohol, marijuana, cocaine and amphetamine-type stimulants has been an escalating public health problem for decades, but now use of these substances has become a significant contributor to early onset CVD. While this remains a global phenomenon, the epicenter of substance abuse is rooted in North America where it has been exacerbated by the COVID-19 pandemic. For the first time in history, the United States (US) crossed 100,000 overdose-related deaths in a calendar year. Sadly, Canada's recreational drug abuse problem closely mirrors that of the US. This is indicative of the larger public health crisis unfolding, as we now know that these substances are cardiotoxic and are contributing to the rising levels of premature chronic CVD, including hypertension, arrhythmias, heart failure, stroke, myocardial infarction, arterial dissection, sudden cardiac death and early mortality.

Individualized prediction of risk of ascending aortic syndromes

Objectives

Although ascending aortic diameter changes acutely after dissection, recommendation for prophylactic surgery of thoracic aortic aneurysms rely on data from dissected aortas. In this case-control study we aim to identify risk markers for acute and chronic aortic syndromes of the ascending aorta (ACAS-AA). Furthermore, to develop a predictive model for ACAS-AA.

Methods

We collected data of 188 cases of ACAS-AA and 376 controls standardized to age- and sex of the background population. Medical history and CT-derived aortic morphology were collected. For the dependent outcome ACAS-AA, potential independent risk factors were identified by univariate logistic regression and confirmed in multivariate logistic regression. As post-dissection tubular ascending aortic diameter is prone to expand, this factor was not included in the first model. The individual calculated adjusted odds ratios were then used in ROC-curve analysis to evaluate the diagnostic accuracy of the model. To test the influence of post-ACAS-AA tubular ascending aortic diameter, this was added to the model.

Results

The following risk factors were identified as independent risk factors for ACAS-AA in multivariate analysis: bicuspid aortic valve (OR 20.41, p = 0.03), renal insufficiency (OR 2.9, p<0.01), infrarenal abdominal aortic diameter (OR 1.08, p<0.01), left common carotid artery diameter (OR 1.40, p<0.01) and aortic width (OR 1.07, p<0.01). Area under the curve was 0.88 (p<0.01). Adding post-ACAS-AA tubular ascending aortic diameter to the model, negated the association of bicuspid aortic valve, renal insufficiency, and left common carotid artery diameter. Area under the curve changed to 0.98 (p<0.01).

Conclusions

A high performing predictive model for ACAS-AA, free of ascending aortic diameter, can be achieved. Furthermore, we have identified abdominal aortic ectasia as an independent risk factor of ACAS-AA. Integration of potential biomarkers and morphologic variables, derived from undissected aortas, would probably improve the model.

Acute Cardiovascular Toxicity of Cocaine

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.

Elevated Admission Cardiac Troponin I Predicts Adverse Outcomes of Acute Type B Aortic Dissection after Endovascular Treatment

Background

There is a lack of evidence about the predictive role of serum cardiac troponin I (cTnI) on the long-term adverse outcomes of acute type B aortic dissection (aTBAD) patients after thoracic endovascular aortic repair (TEVAR). In this study, we identified whether cTnI was an independent risk factor of 5-year adverse outcomes for aTBAD patients after TEVAR.

Methods

We reviewed consecutive aTBAD patients without previous heart disease who were admitted for TEVAR. The total study population was divided into the cTnI(+) group (≥0.03 ng/mL) and the cTnI(−) group (<0.03 ng/mL) according to the time-dependent receiver operating characteristic curve analysis. The differences in clinical characteristics, operative details and clinical outcomes were compared between the two groups.

Results

There was no difference in age and male prevalence between the two groups. Compared with the cTnI(−) group, the incidence of chronic kidney disease was higher in patients with cTnI ≥0.03 ng/mL. In addition, the cTnI(+) group presented with more frequent premature beats and non-myocardial-infarction ST-T segment changes. In terms of laboratory examinations, white blood cell counts, neutrophil counts, serum D-dimer and serum fibrin degradation products showed an increase in the cTnI(+) group, while lymphocyte and platelet counts showed a decrease in these patients. Patients with elevated cTnI suffered from increased risks of 5-year aortic-related adverse events (hazard ratio, HR = 1.822, 95% confidence interval, CI: 1.094–3.035; p = 0.021) and all-cause mortality (HR = 4.009, 95% CI: 2.175–7.388; p < 0.001).

Conclusion

Among aTBAD patients without previous heart disease, preoperative elevated cTnI identified patients at an increased risk of long-term adverse outcomes after TEVAR.

Cocaine Use and White Matter Hyperintensities in Homeless and Unstably Housed Women

OBJECTIVES

Cocaine use has been linked to stroke in several studies. However, few studies have considered the influence of cocaine use on stroke mechanisms such as small vessel disease (SVD). We conducted a study to assess associations between the toxicology-confirmed use of multiple drugs, including cocaine, and a marker of SVD, white matter hyperintensities (WMH).

MATERIALS AND METHODS

We conducted a nested case-control study (n = 30) within a larger cohort study (N = 245) of homeless and unstably housed women recruited from San Francisco community venues. Participants completed six monthly study visits consisting of an interview, blood draw, vital sign assessment and baseline brain MRI. We examined associations between toxicology-confirmed use of multiple substances, including cocaine, methamphetamine, heroin, alcohol and tobacco, and WMH identified on MRI.

RESULTS

Mean study participant age was 53 years, 70% of participants were ethnic minority women and 86% had a history of cocaine use. Brain MRIs indicated the presence of WMH (i.e., Fazekas score>0) in 54% (18/30) of imaged participants. The odds of WMH were significantly higher in women who were toxicology-positive for cocaine (Odd Ratio=7.58, p=0.01), but not in women who were toxicology-positive for other drugs or had several other cerebrovascular risk factors.

CONCLUSIONS

Over half of homeless and unstably housed women showed evidence of WMH. Cocaine use is highly prevalent and a significant correlate of WMH in this population, while several traditional CVD risk factors are not. Including cocaine use in cerebrovascular risk calculators may improve stroke risk prediction in high-risk populations and warrants further investigation.

Cracking the Opium Den: Cardiothoracic Manifestations of Drug Abuse

Recreational drug use is increasing worldwide, with emergency room visits and total deaths from drug overdose rising in recent years. Complications from prescription and recreational drug use may result from the biochemical effects of the drugs themselves, impurities mixed with substances, or from causes related to the method of drug administration. The presentation of drug overdose may be complex due to multisubstance abuse, including cigarette smoking and alcoholism, and can impact any organ system. Patients may present without history, and radiologists may be the first clinicians to suggest the diagnosis. We aim to explore the cardiothoracic manifestations of drug abuse and their multimodality imaging manifestations.

Genetic aortic disease epidemiology, management principles, and disparities in care

Patients with syndromic and nonsyndromic heritable aortopathies (also known as genetic aortic disease) are a heterogeneous group of patients who present at younger ages with more rapid growth of aortic aneurysms and/or increased frequency of dissections compared with patients with atherosclerotic aortopathies. In this review, we describe the etiology, epidemiology, and appropriate care delivery for these conditions at each stage of management. Within each section, we discuss sex, gender, and race differences and highlight disparities in care and knowledge. We then discuss the role of the vascular team throughout the cycle of care and the evolving inclusion of patient input in research. This understanding is essential to the creation of effective health care policies that support equitable, appropriate, and patient-centered clinical practices.

Pathophysiology and management of recreational drug-related acute coronary syndrome: ANMCO position statement

Recreational drug use may cause coronary artery disease through several mechanisms. An increasing number of young patients with drug-related acute coronary syndrome have been reported over recent years. The present position statement reports the most recent epidemiological data on acute coronary syndrome in the setting of drug abuse, describes the main pathophysiological mechanisms underlying coronary artery disease and acute events in these patients, and provides practical recommendations on management and an overview of prognosis.

Cocaine-Related Aortic Dissection: what do we know?

Introduction

Cocaine use is known to be associated with an increased risk for vascular diseases. It is likely to trigger or increase the risk for an aortic dissection. We conducted an analysis of 45 cases of cocaine-related aortic dissection to further characterize the clinical features and outcomes of this patient cohort.

Methods

Our study cohort of 45 patients consisted of 11 cases from our institutional database and 34 published case reports.

Results

The observed cases of acute aortic dissection related to cocaine use showed a high proportion of young (41.3±8.67 years) and male (88.9%) patients. Most of the cases (75%) were classified as Stanford type A. Also, in 75% of the cases, cocaine use was prevalent for more than one year. Median time from last cocaine use to onset of symptoms was one hour. In-hospital mortality was 21.4%, while additional 11.9% of the cases died before arriving at the hospital.

Conclusion

Acute aortic dissection related to cocaine use occurs in predominantly young male patients and has a dismal outcome when compared to all comer series.

Cerebrovascular and cardiovascular diseases caused by drugs of abuse

Drugs such as stimulants, sedatives, sleeping pills, and narcotics are associated with drug abuse and are therefore regulated by law. Physical dependence on these drugs is sometimes difficult to control despite an awareness of the problems they cause in daily life and the harm they can cause to the body. Drug dependence is a social problem worldwide, and the physical implications are serious. Many of these drugs cause cerebrovascular and cardiovascular diseases, which often require emergency medical treatment. Differential diagnosis is essential because of the likelihood of life-threatening events, especially among young people who exhibit cerebrovascular and cardiovascular diseases without any of the typical risk factors. Drugs of abuse, especially stimulants, induce a hyperadrenergic state that evokes vasoconstriction and tachycardia, as well as subsequent ischemic and hemorrhagic stroke, acute coronary syndrome, arrhythmias, and aortic dissection. Chronic drug abuse can also cause cardiac hypertrophy and left ventricular dysfunction. As a treatment for these conditions, sedative drugs can be effective but the use of vasodilators may also be required. There are concerns that the use of both alpha- and beta-adrenergic receptor blockers may cause tachycardia and increased blood pressure. Therefore, careful differential diagnosis and selection of therapeutic agents is required.

Cardiovascular Disease and Homelessness

Cardiovascular disease (CVD) is a major cause of death among homeless adults, at rates that exceed those in nonhomeless individuals. A complex set of factors contributes to this disparity. In addition to a high prevalence of cigarette smoking and suboptimal control of traditional CVD risk factors such as hypertension and diabetes, a heavy burden of nontraditional psychosocial risk factors like chronic stress, depression, heavy alcohol use, and cocaine use may confer additional risk for adverse CVD outcomes beyond that predicted by conventional risk estimation methods. Poor health care access and logistical challenges to cardiac testing may lead to delays in presentation and diagnosis. The management of established CVD may be further challenged by barriers to medication adherence, communication, and timely follow-up. The authors present practical, patient-centered strategies for addressing these challenges, emphasizing the importance of multidisciplinary collaboration and partnership with homeless-tailored clinical programs to improve CVD outcomes in this population.

Cocaine use is associated with worse outcomes in patients treated with thoracic endovascular repair for type B aortic dissection

OBJECTIVE

To describe and compare the clinical and anatomical characteristics and outcomes of patients with and without known cocaine use who underwent thoracic endovascular repair for type B aortic dissections.

METHODS

Between January 2012 and January 2017, 186 patients underwent thoracic endovascular repair for type B aortic dissection at our institution. Clinical data and anatomical characteristics were collected under an institutional review board-approved protocol. Survival, reintervention, complications, and characteristics of dissection were compared between patients with cocaine use (C+; n = 14) and those with no known cocaine use (C-; n = 172).

RESULTS

Cocaine users were more likely to be young African American males who smoked. They tended to present with more extensive dissections as evidenced by larger false lumen diameters. They also had higher rates of endoleaks and more reinterventions.

CONCLUSIONS

These results suggest that special care should be taken to provide close follow-up for these patients.

Sudden Death Due to Thoracic Aortic Dissection in Young People: A Multicenter Forensic Study

INTRODUCTION AND OBJECTIVES

Thoracic aortic dissection (TAD) is infrequent in young people and its characteristics differ from those in the adult population. This study aimed to analyze the clinical and pathological characteristics of sudden death due to TAD in people aged 1 to 35 years.

METHODS

Multicenter population-based study based on forensic autopsies conducted in the provinces of Biscay (1991-2016), Valencia (2000-2016), and Seville (2004-2016).

RESULTS

We identified 35 individuals with sudden death due to TAD (80% males), with a mean age of 29±5 years. The incidence was 0.09/100 000 inhabitants/y. Eighteen persons had at least 1 risk factor for TAD, and this figure increased to 29 when postmortem findings were included: congenital heart disease (n=16), suspicion of familial TAD (n=11), cocaine use (n=6), and hypertension (n=5). Twenty-four individuals, 12 with at least 1 risk factor, had prodromal symptoms, and 16 of them visited their physician, but TAD was not suspected in any of them. The most frequent symptom was chest pain (n=12). The main autopsy findings were cystic degeneration of the media (n=27), dilatation of the ascending aorta (n=21), cardiac hypertrophy (n=20), and bicuspid aortic valve (n=14).

CONCLUSIONS

The incidence of sudden death due to TAD in young people was very low. The most frequent risk factors were congenital heart disease followed by suspicion of familial TAD and cocaine use. TAD should be included in the differential diagnosis of chest pain in young people, mainly male patients with at least 1 risk factor.

The Cardiovascular Effects of Cocaine

Cocaine is the leading cause for drug-abuse-related visits to emergency departments, most of which are due to cardiovascular complaints. Through its diverse pathophysiological mechanisms, cocaine exerts various adverse effects on the cardiovascular system, many times with grave results. Described here are the varied cardiovascular effects of cocaine, areas of controversy, and therapeutic options.

Evaluation of Acute Aortic Dissection Type a Factors and Comparison the Postoperative Clinical Outcomes between Two Surgical Methods

BACKGROUND

Although aortic dissection is a rare disease, it causes high level of mortality. If ascending aorta gets involved in this disease, it is known as type A. According to small number of studies about this disease in Iran, this study conducted to detect the factors related to acute aortic dissection type A, its surgery consequences and the factors affecting them.

MATERIALS AND METHODS

In this historical cohort study, all patients having acute aortic dissection type A referring to Chamran Hospital from 2006 to 2012 were studied. The impact of two surgical methods including antegrade cerebral perfusion (ACP) and retrograde cerebral one (RCP) on surgical and long-term mortality and recurrence of dissection was determined. The relation of mortality rate and hemodynamic instability before surgery, age more than 70 years old, ejection fraction lower than 50%, prolonged cardiopulmonary bypass pump (CPBP) time and excessive blood transfusion, was assessed.

RESULTS

Surgery and long-term mortality and recurrence of dissection were 35.3%, 30.8% and 30.4%. Surgical and long-term death in the patients being operated by ACP method was lower than those one being operated by RCP (P < 0.001). Excessive blood transfusion and unstable hemodynamic condition had significant effect on surgical mortality (P = 0.014, 0.030, respectively). CPBP time and unstable hemodynamic condition affected long-term mortality significantly (P = 0.002).

CONCLUSION

The result found that ACP is the preferable kind of surgery in comparison with RCP according to the surgical and long-term mortality.

Vascular disease in cocaine addiction

Cocaine, a powerful vasoconstrictor, induces immune responses including cytokine elevations. Chronic cocaine use is associated with functional brain impairments potentially mediated by vascular pathology. Although the Crack-Cocaine epidemic has declined, its vascular consequences are increasingly becoming evident among individuals with cocaine use disorder of that period, now aging. Paradoxically, during the period when prevention efforts could make a difference, this population receives psychosocial treatment at best. We review major postmortem and in vitro studies documenting cocaine-induced vascular toxicity. PubMed and Academic Search Complete were used with relevant terms. Findings consist of the major mechanisms of cocaine-induced vasoconstriction, endothelial dysfunction, and accelerated atherosclerosis, emphasizing acute, chronic, and secondary effects of cocaine. The etiology underlying cocaine's acute and chronic vascular effects is multifactorial, spanning hypertension, impaired homeostasis and platelet function, thrombosis, thromboembolism, and alterations in blood flow. Early detection of vascular disease in cocaine addiction by multimodality imaging is discussed. Treatment may be similar to indications in patients with traditional risk-factors, with few exceptions such as enhanced supportive care and use of benzodiazepines and phentolamine for sedation, and avoiding β-blockers. Given the vascular toxicity cocaine induces, further compounded by smoking and alcohol comorbidity, and interacting with aging of the crack generation, there is a public health imperative to identify pre-symptomatic markers of vascular impairments in cocaine addiction and employ preventive treatment to reduce silent disease progression.

Asymptomatic Cocaine Abuse - Myocardial Tissue Characterization Using Cardiac Biomarkers and Cardiovascular Magnetic Resonance Imaging

BACKGROUND

Use of cocaine is widespread and associated with several cardiovascular diseases. Recent CMR studies indicate frequent myocardial scar/fibrosis in asymptomatic cocaine abusers (CA).Methods and Results:This study used a combination of advanced CMR tissue characterization techniques, including late gadolinium enhancement (LGE) for focal, and extracellular volume (ECV) imaging for diffuse myocardial injury/fibrosis, with circulating biomarkers for a comprehensive characterization of myocardial injury. We included 20 cardiac asymptomatic CA and a control group of 20 healthy volunteers. The comprehensive assessment included physical examination, resting ECG, exercise ECG, cardiac biomarkers, transthoracic echocardiogram and CMR. We did not find significant differences between CA and controls either in functional CMR parameters such as LVEDVi, LVESVi, LVEF, LV mass index, or in global myocardial ECV. Neither CA nor controls had evidence of myocardial edema on T2-weighted CMR, but 8 CA (40%), and none of the controls had focal myocardial scar (P<0.01). Interestingly, CA with focal myocardial scar on LGE had significantly higher high-sensitivity troponin I (hs-TNI) compared with CA without focal scar (median, 1.7 ng/L; IQR, 1.3-2.5 ng/L vs. 0.6 ng/L; 0.4-1.3 ng/L; P<0.01).

CONCLUSIONS

Focal myocardial injury in terms of subtle LGE in 40% of asymptomatic CA was associated with higher hs-TNI. Comprehensive assessment including advanced ECV imaging indicates a focal rather than diffuse pattern of myocardial involvement in asymptomatic CA.

Higher prevalence of detectable troponin I among cocaine-users without known cardiovascular disease

BACKGROUND

While cocaine use is an established risk factor for acute cardiovascular complications, associations between cocaine use and markers of cardiac injury outside of acute hospital presentation remain poorly characterized. We leveraged advances in cardiac troponin (cTnI) testing to assess low but clinically meaningful levels of cardiac injury among cocaine users and non-users.

METHODS

We conducted a case control study comparing cTnI levels by the presence of cocaine among patients presenting for non-cardiac care in an urban safety net hospital. Samples were chosen sequentially among those for which urine drug screens were ordered by providers hospital-wide.

RESULTS

During 2015, 14% of all hospital drug screens ordered were cocaine-positive. Among unique persons providing cocaine-positive (N=100) and cocaine-negative (N=100) samples, 37% were female, 45% were African-American and the median age was 51. Detectable cTnI (> 0.02ng/mL) was observed in 21 samples (11%). It was more common in subjects using cocaine (Adjusted OR=2.81; 95% CI=1.03-7.65), but not other drugs. Moreover, there was a significant correlation between concentrations of cTnI and the cocaine metabolite, benzoylecgonine (Spearman Correlation=0.34, p<0.01).

CONCLUSIONS

Among urban safety net hospital patients, 11% had detectable cTnI, and cTnI concentration was significantly correlated with benzoylecgonine concentration. While these preliminary results require additional confirmation, they suggest the potential utility of considering cocaine use as more than just an episodic exposure leading to acute cardiac events. The consideration of cocaine use as an ongoing chronic exposure leading to subclinical cardiac injury may improve risk-stratification and patient outcomes in populations where cocaine use is high.

Point of Care Echocardiography in an Acute Thoracic Dissection with Tamponade in a Young Man with Chest Pain, Tachycardia, and Fever

BACKGROUND

Although thoracic aortic dissections are uncommon in young patients, they must be considered in the differential diagnosis in the presence of chest pain and abnormal vital signs. Although computed tomography angiography is the test of choice for thoracic dissection in the emergency department, point of care (POC) transthoracic echocardiography has a high specificity in the diagnosis of this disease. It is especially helpful in patients with proximal ascending dissections in the presence of a pericardial effusion.

CASE REPORT

This case report illustrates a young patient presenting with chest pain, persistent tachycardia, and fever with a presumed upper respiratory infection who had an ascending thoracic dissection with tamponade discovered on POC echocardiography. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POC echocardiography should be an important part of the algorithm in young patients presenting with chest pain and abnormal vital signs that do not improve with supportive measures. Definitive care in patients who present with a thoracic aortic dissection in the presence of cardiac tamponade diagnosed on POC echocardiography should not be delayed in order to wait for other imaging methods to be performed. POC echocardiography may expedite care and treatment in young patients presenting with this deadly disease.

Aortic Dissection: A Dreaded Disease with Many Faces

Aortic dissection is a relatively uncommon but catastrophic illness classically thought to present with acute, sharp, chest pain with radiation to the back. However, aortic dissection can manifest in a number of different ways that include congestive heart failure, inferior myocardial infarction, stroke, focal pulse and neurologic deficits, abdominal pain, or acute renal failure. According to some studies, only about 80% of patients with type A dissection present with severe anterior chest pain, and only about 60% describe their pain as being sharp. Another series reports that treating clinicians fail to initially entertain the diagnosis of aortic dissection in up to 35% of cases. Many patients later found to have aortic dissection are initially suspected to have other conditions such as acute coronary syndrome, pericarditis, pulmonary embolism, or even cholecystitis. In this article we present a case of an unusual presentation of aortic dissection and a review of this condition.

Consensus statement on surgical pathology of the aorta from the Society for Cardiovascular Pathology and the Association For European Cardiovascular Pathology: II. Noninflammatory degenerative diseases - nomenclature and diagnostic criteria

Surgical aortic specimens are usually examined in Pathology Departments as a result of treatment of aneurysms or dissections. A number of diseases, genetic syndromes (Marfan syndrome, Loeys-Dietz syndrome, etc.), and vasculopathic aging processes involved in vascular injury can cause both distinct and nonspecific histopathologic changes with degeneration of the media as a common denominator. Terminology for these changes has varied over time leading to confusion and inconsistencies. This consensus document has established a revised, unified nomenclature for the variety of noninflammatory degenerative aortic histopathologies seen in such specimens. Older terms such as cystic medial necrosis and medionecrosis are replaced by more technically accurate terms such as mucoid extracellular matrix accumulation (MEMA), elastic fiber fragmentation and/or loss, and smooth muscle cell nuclei loss. A straightforward system of grading is presented to gauge the extent of medial degeneration and synoptic reporting tables are provided. Herein we present a standardized nomenclature that is accessible to general pathologists and useful for future publications describing these entities.

Structure of the Elastin-Contractile Units in the Thoracic Aorta and How Genes That Cause Thoracic Aortic Aneurysms and Dissections Disrupt This Structure

The medial layer of the aorta confers elasticity and strength to the aortic wall and is composed of alternating layers of smooth muscle cells (SMCs) and elastic fibres. The SMC elastin-contractile unit is a structural unit that links the elastin fibres to the SMCs and is characterized by the following: (1) layers of elastin fibres that are surrounded by microfibrils; (2) microfibrils that bind to the integrin receptors in focal adhesions on the cell surface of the SMCs; and (3) SMC contractile filaments that are linked to the focal adhesions on the inner side of the membrane. The genes that are altered to cause thoracic aortic aneurysms and aortic dissections encode proteins involved in the structure or function of the SMC elastin-contractile unit. Included in this gene list are the genes encoding protein that are structural components of elastin fibres and microfibrils, FBN1, MFAP5, ELN, and FBLN4. Also included are genes that encode structural proteins in the SMC contractile unit, including ACTA2, which encodes SMC-specific α-actin and MYH11, which encodes SMC-specific myosin heavy chain, along with MYLK and PRKG1, which encode kinases that control SMC contraction. Finally, mutations in the gene encoding the protein linking integrin receptors to the contractile filaments, FLNA, also predispose to thoracic aortic disease. Thus, these data suggest that functional SMC elastin-contractile units are important for maintaining the structural integrity of the aorta.

Complete Angiographic Resolution of Cocaine Induced Coronary Artery Dissection within Eight Days without Coronary Stenting--A Case Report

INTRODUCTION

Coronary dissection is a rarely reported complication of cocaine use for which there are no specific guidelines on management despite the widespread use of the drug.

METHODS

We report a case of a 26-year-old otherwise fit and healthy Caucasian male smoker who presented to our facility with an infero-lateral ST elevation myocardial infarction (STEMI) following nasal inhalation of 1 gram of cocaine. Coronary angiography showed a mid left anterior descending (LAD) artery dissection with distal occlusive embolism and another dissection of the distal right coronary artery (RCA) with embolism and occlusion of the distal posterolateral branch.

OUTCOME

Wiring of both vessels with a High-Torque Floppy wire successfully re-established TIMI 3 flow with relief of pain and resolution of his ST-segment elevation. Given the absence of any flow-limiting lesions, stenting was avoided. He was subsequently put on a combination of therapeutic dose enoxaparin, aspirin, ticagrelor, atorvastatin and metoprolol. A repeat angiogram eight days later showed complete healing of the dissections.

CONCLUSION

This case shows that percutaneous management without stenting coupled with aggressive anti-coagulation of cocaine induced coronary dissection may result in an acceptable outcome especially in a young otherwise fit and healthy patient.

Management of aortic dissection: medical therapy and intervention. Is there a growing role for endovascular techniques?

OPINION STATEMENT

Historically, type B aortic dissection was managed as a medical condition with limited surgical intervention unless aortic rupture occurred. Today, however, evidence is building that highlights the importance of strict medical management, timely surveillance, and windows of opportunity for surgical intervention to address both early and late aortic-based morbidities.

Effects of energy drinks on blood pressure, heart rate, and electrocardiographic parameters: An experimental study on healthy young adults

Objective:

To evaluate the effects of the consumption of energy drinks on cardiovascular parameters in a group of healthy young individuals.

Methods:

In a quasi-experimental study, 44 healthy adult participants aged between 15 and 30 years were evaluated. The blood pressure (BP) as well as electrocardiographic indices, including heart rate (HR), PR interval, QRS duration, corrected QT (QTc) interval, and ST-T changes were recorded before consumption of a caffeine-containing energy drink and at the specific time points over a 4-h test duration.

Results:

We found statistically significant HR decline (p=0.004) and more frequent ST-T changes (p=0.004) after the participants consumed the energy drink. However, readings for systolic BP (p=0.44), diastolic BP (p=0.26), PR interval (p=0.449), QRS duration (p=0.235), and QTc interval (p=0.953) showed no significant change post-consumption.

Conclusion:

In conclusion, we demonstrated that the consumption of energy drinks could contribute to HR decline and ST-T change in healthy young adults.

Recent cocaine use is a significant risk factor for sudden cardiovascular death in 15-49-year-old subjects: a forensic case-control study

AIMS

The aims of the present study were to: (i) evaluate the prevalence of recent cocaine use in adolescents and young adults who had died by sudden cardiovascular death (SCVD); (ii) assess if recent cocaine use was associated with an increased risk of SCVD; and (iii) determine the demographic, clinical-pathological and toxicological characteristics of SCVD related to recent cocaine use.

DESIGN

This was a case-control autopsy-based observational retrospective study.

SETTING/CASES

Cases were all SCVD in individuals aged between 15 and 49 years during the period ranging from 1 January 2003 to 31 December 2009, with autopsies performed in Biscay, Spain. Medico-legal sudden deaths not due to cardiovascular diseases (SnoCVD) were used as the control group. In all deaths a complete autopsy and toxicological and histopathological studies were carried out. Recent cocaine use was considered when cocaine and/or benzoylecgonine were detected in blood.

MEASUREMENTS

The risk for SCVD according to demographic variables (sex and age), cardiovascular risk factors (obesity, hypertension, diabetes and smoking) and toxicological variables (opioids, benzodiazepines, amphetamines, cannabis and alcohol) was analysed using three logistic regression models. We also estimated the prevalence of recent cocaine use in the general population aged 15-49 years based on the projection of population surveys.

FINDINGS

Recent cocaine use was significantly higher in the SCVD group (27 of 311 subjects, 9%) than in the SnoCVD group (three of 126 subjects, 2%). In a full logistic regression controlling for all recorded covariates, the main risk factor for SCVD was recent cocaine use (odds ratio 4.10; 95% confidence interval 1.12-15.0). Compared with the estimated data in the general population, the prevalence of recent cocaine use was 13-58 times higher in people with SCVD.

CONCLUSIONS

Recent cocaine use is associated significantly with an increased risk for sudden cardiovascular death in people aged 15-49 years.

Cocaine-related aortic dissection: lessons from the International Registry of Acute Aortic Dissection

BACKGROUND

Acute aortic dissection associated with cocaine use is rare and has been reported predominantly as single cases or in small patient cohorts.

METHODS

Our study analyzed 3584 patients enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2012. We divided the population on the basis of documented cocaine use (C+) versus non cocaine use (C-) and further stratified the cohorts into type A (33 C+/2332, 1.4%) and type B (30 C+/1252, 2.4%) dissection.

RESULTS

C+ patients presented at a younger age and were more likely to be male and black. Type B dissections were more common among C+ patients than in C- patients. Cocaine-related acute aortic dissection was reported more often at US sites than at European sites (86.4%, 51/63 vs 13.6%, 8/63; P < .001). Tobacco use was more prevalent in the C+ cohort. No differences were seen in history of hypertension, known atherosclerosis, or time from symptom onset to presentation. Type B C+ patients were more likely to be hypertensive at presentation. C+ patients had significantly smaller ascending aortic diameters at presentation. Acute renal failure was more common in type A C+ patients; however, mortality was significantly lower in type A C+ patients.

CONCLUSIONS

Cocaine use is implicated in 1.8% of patients with acute aortic dissection. The typical patient is relatively young and has the additional risk factors of hypertension and tobacco use. In-hospital mortality for those with cocaine-related type A dissection is lower than for those with non cocaine-related dissection, likely due to the younger age at presentation.

Long term effects of cocaine on the heart assessed by cardiovascular magnetic resonance at 3T

BACKGROUND

Cocaine is an addictive, sympathomimetic drug with potentially lethal effects. The prevalence and features of cocaine cardiotoxicity are not well known. We aimed to assess these effects using a comprehensive cardiovascular magnetic resonance (CMR) protocol in a large group of asymptomatic cocaine users.

METHODS

Consecutive (n = 94, 81 males, 36.6 ±7 years), non-selected, cocaine abusers were recruited and had a medical history, examination, ECG, blood test and CMR. The CMR study included measurement of left and right ventricular (LV, RV) dimensions and ejection fraction (EF), sequences for detection of myocardial oedema and late gadolinium enhancement (LGE). Images were compared to a cohort of healthy controls.

RESULTS

Years of regular cocaine use were 13.9 ± 9. When compared to the age-matched healthy cohort, the cocaine abusers had increased LV end-systolic volume, LV mass index and RV end-systolic volume, with decreased LVEF and RVEF. No subject had myocardial oedema, but 30% had myocardial LGE indicating myocardial damage.

CONCLUSIONS

CMR detected cardiovascular disease in 71% of this cohort of consecutive asymptomatic cocaine abusers and mean duration of abuse was related to probability of LV systolic dysfunction.

Acute aortic dissection in blacks: insights from the International Registry of Acute Aortic Dissection

BACKGROUND

Few data exist on race-related differences in acute aortic dissection patients.

METHODS

We evaluated black (n = 189, 14%) or white (n = 1165, 86%) patients (mean age 62.8 ± 15.3 years; 36.4% women) enrolled in 13 US centers participating in the International Registry of Acute Aortic Dissection. We excluded patients of other racial descent.

RESULTS

Type B acute aortic dissection was more frequent in the black cohort (52.4% vs 39.3%, P = .001). Black patients were younger (mean age 54.6 ± 12.8 years vs 64.2 ± 15.2 years, P <.001) and more likely to have a history of cocaine abuse (12% vs 1.6%, P <.001), hypertension (89.7% vs 73.9%, P <.001), and diabetes (13.2% vs 6.4%, P = .001). Conversely, they were less likely to have bicuspid aortic valve (1.8% vs 5.8%, P = .029), iatrogenic dissection (0.5% vs 4.5%, P = .010), and prior aortic dissection repair (7.7% vs 12.8%, P = .047). Presenting features were similar except for more abdominal pain (44.6% vs 30.6%, P <.001) and left ventricular hypertrophy on echocardiogram (44.2% vs 20.1%, P <.001) in blacks. Management was similar. Hypotension/shock/tamponade was less common (7.6% vs 20.1%, P <.001), whereas acute kidney failure was more common (41.0% vs 21.7%, P <.001) in blacks. Mortality was similar in-hospital (14.3% vs 19.1%, P = .110, odds ratio 0.704, 95% confidence interval 0.457-1.085) and at 3 years postdischarge, as evaluated by Kaplan-Meier survival analysis (22.0% vs 14.3%, P = .224, SE = 0.062 and 0.018).

CONCLUSIONS

Our study shows differences in type, etiology, and presentation of blacks and whites with acute aortic dissection, yet similar mortality for these cohorts.

Neurological soft signs in individuals with pathological gambling

Increased neurological soft signs (NSSs) have been found in a number of neuropsychiatric syndromes, including chemical addiction. The present study examined NSSs related to perceptual-motor and visuospatial processing in a behavioral addiction viz., pathological gambling (PG). As compared to mentally healthy individuals, pathological gamblers displayed significantly poorer ability to copy two- and three-dimensional figures, to recognize objects against a background noise, and to orient in space on a road-map test. Results indicated that PG is associated with subtle cerebral cortical abnormalities. Further prospective clinical research is needed to address the NSSs' origin and chronology (e.g., predate or follow the development of PG) as well as their response to therapeutic interventions and/or their ability to predict such a response.