Myocardial infarction in patients who have cocaine-associated chest pain is not uncommon. No clinical parameter available to the physician can adequately identify patients at very low risk for myocardial infarction. Therefore, all patients with cocaine-associated chest pain should be evaluated for myocardial infarction.

The application of EBM to routine practice by physicians is constrained by deficient EBM skills, limited access to evidence, lack of time, and cognitive and environmental factors. Targeted education in EBM and systems that quickly deliver high-quality evidence at the point of care are needed in realising the full potential of EBM to improve care.

Objective: To determine the one-year mortality and incidence of myocardial infarction (MI) post-hospital discharge or ED release for patients with cocaine-associated chest pain.Methods: A prospective, observational study of an inception cohort of consecutive patients who presented to one of four municipal hospital EDs with cocaine-associated chest pain. Patients were followed for one year from the end of the enrollment period. Main outcome parameters were the one-year actuarial survival and the frequency of nonfatal MI.Results: Mortality data were available for all 203 patients at a mean of 408 days. Additional clinical information was available for 185 patients (91%). There were six deaths (one-year actuarial survival 98%; 95% CI, 95-100%); none from MI. Nonfatal MI occurred in two patients (1%; 95% CI, 0-2%). Continued cocaine use was common (60%; 95% CI, 52-68%) and was associated with recurrent chest pain (75% vs 31%, p < 0.0001). No MI or death was reported for patients who claimed to have ceased cocaine use. Conclusions:Patients who presented with cocaine-associated chest pain commonly continued to use cocaine after discharge. Urgent evaluation of coronary anatomy or cardiac stress tests may not be necessary for patients for whom MI is ruled out and who do not have recurrent potentially ischemic pain. The subsequent risk for MI and death in this group appears to be low. Intervention strategies should emphasize cessation of cocaine use. Acad 180ACADEMIC EMERGENCY MEDICINE MAR 1995 VOL 2/NO 3 1 In the past decade the incidence of cocaine abuse has increased substantially. Twenty-four million Americans have used cocaine at least once,' and 5 million use it regularly.2 As a result, emergency physicians have witnessed an almost 20-fold increase in the number of cocaine-related complaint^.^ By 1986, cocaine had become the most common iIlicit drug of abuse in patients presenting to the ED,4 comprising more than 40% of all such cases.5 Chest pain is the most frequent cocaineassociated complaint6 and myocardial infarction (MI) occurs in approximately 6% of patients with cocaineassociated chest pain.'-" Chronic cocaine use accelerates coronary artery atherosclerosis. l 2 -I 8 Cocaine-using patients with chest pain may therefore represent a high-risk cohort predisposed to ischemic heart disease. Whether these patients should be treated and evaluated like patients with new-onset or unstable angina (unrelated to cocaine) has not been studied. This study was designed to determine the incidence of MI and death over the year following presentation with cocaine-associated chest pain. I METHODS Study Design' This study was a prospective, observational study of an inception cohort of patients who were identified at the time of ED presentation for cocaine-associated chest pain. Patients were followed for one year from the end of the study period to identify the frequency of death and nonfatal MI post-hospital discharge or post-ED release. Population and SettingAll patients with anterior, precordial, or left-sided che...