Cocaine‐Using Patients With a Normal or Nondiagnostic Electrocardiogram: Single‐Photon Emission Computed Tomography Myocardial Perfusion Imaging and Outcome

Abstract

Background Few trials have examined the outcomes of patients who use cocaine with chest pain and who have a normal or nondiagnostic electrocardiogram (ECG) and the use of single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI). Hypothesis We sought to compare the characteristics and overall outcomes in cocaine users vs non-cocaine users presenting to the emergency department with a normal/nondiagnostic ECG and to assess the value of rest MPI in both of these populations. Methods Patients with symptoms compatible with myocardial ischemia, suspected acute coronary syndrome (ACS), and a normal/nondiagnostic ECG were enrolled in the Emergency Room Assessment of Sestamibi for Evaluation of Chest Pain (ERASE Chest Pain) trial, a randomized controlled trial designed to evaluate the impact of rest MPI on triage decisions. Cocaine users (n = 294) were compared to non-cocaine users (n = 2180). Cocaine users were younger than non-cocaine users, and 72% were male. Results Among the cocaine users, 2.4% had a myocardial infarction, 1.4% required percutaneous coronary intervention, and none of the patients underwent coronary artery bypass graft surgery. Among cocaine users with a final diagnosis of not ACS, randomization of patients to rest SPECT MPI resulted in an appropriate reduction in hospital admissions in both the cocaine users (P = 0.011) and the non-cocaine users (P < 0.001), suggesting improved triage when MPI was used. Conclusions Cocaine users with a normal/nondiagnostic ECG are at low risk of cardiac events. Even though cocaine users are at low risk of cardiac events, SPECT MPI remains effective in the risk stratification and improves triage management decisions resulting in lower admission rates and more discharges to home.

Cardiovascular consequences of cocaine use

“…In such patients, SPECT MPI was able to reliably predict myocardial infarction and/or need for percutaneous intervention and reduce unnecessary admissions [75]. Cost-effectiveness analyses suggest that for patients at intermediate risk of coronary artery disease, SPECT MPI provides a more costeffective approach, due largely to greater accuracy, than a stress ECG [76].…”

“…In the recent Emergency Room Assessment of Sestamibi for Evaluation of Chest Pain (ERASE Chest Pain) trial, Hendel et al [75] identified single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI) as a useful diagnostic tool in cocaine-using patients with symptoms of myocardial ischemia and a normal or non-diagnostic ECG. In such patients, SPECT MPI was able to reliably predict myocardial infarction and/or need for percutaneous intervention and reduce unnecessary admissions [75].…”

“…However, several potential diagnostic tools and therapies for cocaine-induced cardiovascular disease have been described, such as SPECT MPI as a diagnostic tool to prevent unnecessary admission [75], intravenous sodium bicarbonate or lipid emulsion infusions or radiofrequency ablation therapy for cocaine-induced cardiac arrhythmia [94][95][96], and drugs targeting mitochondrial oxidation [19] or platelet-von Willebrand factor interaction [26], but these require additional research before they can be recommended for routine use or contribute to development of standard diagnostic and therapeutic practices.…”

Impact of an Abbreviated Cardiac Enzyme Protocol to Aid Rapid Discharge of Patients with Cocaine-associated Chest Pain in the Clinical Decision Unit

“…Ruling out cardiac events more rapidly should involve the use of additional imaging, provocative testing, or more frequent serum biomarkers for detecting myocardial damage. Hendel and colleagues reported on the use of single-photon emission computed tomography myocardial perfusion imaging (MPI) in 151 patients with cocaine chest pain and found that it effectively ruled out cardiac events and lowered admission rates 15. Paraschin and colleagues applied cardiac CT angiography (CTA) in 24 cocaine users presenting with chest pain.…”

“…Hendel and colleagues reported on the use of single-photon emission computed tomography myocardial perfusion imaging (MPI) in 151 patients with cocaine chest pain and found that it effectively ruled out cardiac events and lowered admission rates. 15 Paraschin and colleagues applied cardiac CT angiography (CTA) in 24 cocaine users presenting with chest pain. They found that cardiac CTA was normal in 96% of patients, and positive in only 1 patient (4%) who had non-significant coronary stenosis.…”