Cocaine‐associated Chest Pain: One‐year Follow‐up

Abstract

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...

Management of Cocaine-Associated Chest Pain and Myocardial Infarction

“…In another cohort of 203 patients with cocaine-associated chest pain followed up for 1 year, 60% reported continued cocaine use. 39 Although no MI or death occurred among those claiming abstinence, 2 nonfatal MIs and 6 deaths occurred in patients with persistent cocaine use (although none were attributed to MI). Weber et al 49 reported a 1.6% rate of nonfatal MI during a 30-day follow-up of patients who presented with cocaine-associated chest pain and in whom MI was excluded.…”

“…Recurrent chest pain is less common and MI and death are rare among patients who discontinue cocaine. 39,49 No established drug treatments exist for cocaine dependency, however, and recidivism is high among patients with cocaine-associated chest pain (60% admit to cocaine use in the next year). 39 Several options for psychosocial intervention exist, including individual and group counseling, psychotherapy, and cognitive therapy.…”

“…39,49 No established drug treatments exist for cocaine dependency, however, and recidivism is high among patients with cocaine-associated chest pain (60% admit to cocaine use in the next year). 39 Several options for psychosocial intervention exist, including individual and group counseling, psychotherapy, and cognitive therapy. Preliminary data suggest that a combination of intensive group and individual drug counseling has the greatest impact on recurrent cocaine use.…”

“…Postdischarge use of ␤-blockers, although clearly beneficial among patients with previous MI and cardiomyopathy who do not abuse cocaine, merits special consideration in the setting of cocaine abuse. Because recidivism is high among patients with cocaine-associated chest pain, 39 chronic ␤-blocker use should be reserved for those with the strongest indications, including those with documented MI, left ventricular systolic dysfunction, or ventricular arrhythmias, in whom the benefits may outweigh the risks even among patients at risk for recurrent use of cocaine. This decision should be individualized on the basis of careful risk-benefit assessment and after counseling the patient about the potential negative interactions between recurrent cocaine use and ␤-blockade.…”

Phentolamine therapy for cocaine-associated acute coronary syndrome (CAACS)

“…The differential diagnosis of cocaine-related chest pain is broad and includes acute coronary syndrome (ACS), aortic dissection, pneumothorax, pneumomediastinum, pneumopericardium, and pulmonary infarction [3][4][5][6][7][8]. Diagnostic and treatment strategies are similar to that of other ED patients with chest pain.…”