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Murali N, Ali A, Okolo R, Pirzada S, Stryckman B, Day L, Lemkin D, Sutherland M, Dezman Z, Tran QK. Assessing risk of major adverse cardiac events among patients with chest pain and cocaine use using the HEART score. Am J Emerg Med 2024; 80:29-34. [PMID: 38490096 DOI: 10.1016/j.ajem.2024.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 03/17/2024] Open
Abstract
INTRODUCTION Chest pain (CP), a common presentation in the emergency department (ED) setting, is associated with significant morbidity and mortality if emergency clinicians miss the diagnosis of acute coronary syndrome (ACS). The HEART (History, Electrocardiogram, Age, Risk Factors, Troponin) score had been validated for risk-stratification patients who are at high risk for ACS and major adverse cardiac events (MACE). However, the use of cocaine as a risk factor of the HEART score was controversial. We hypothesized that patients with cocaine-positive (COP) would not be associated with higher risk of 30-day MACE than cocaine-negative (CON) patients. METHODS This retrospective study included adult patients who presented to 13 EDs of a University's Medical System between August 7, 2017 to August 19, 2021. Patients who had CP and prospectively calculated HEART scores and urine toxicology tests as part of their clinical evaluation were eligible. Areas Under The Receiver Operating Curve (AUROC) were calculated for the performance of HEART score and 30-day MACE for each group. RESULTS This study analyzed 46,210 patients' charts, 663 (1.4%) were COP patients. Mean age was statistically similar between groups but there were fewer females in the COP group (26.2% vs 53.2%, p < 0.001). Mean (+/- SD) HEART score was 3.7 (1.4) comparing to 3.1 (1.8, p < 0.001) between COP vs CON groups, respectively. Although more COP patients (54%) had moderate HEART scores (4-6) vs. CON group (35.2%, p < 0.001), rates of 30-day MACE were 1.1% for both groups. HEART score's AUROC was 0.72 for COP and 0.78 for CON groups. AUROC for the Risk Factor among COP patients, which includes cocaine, was poor (0.54). CONCLUSION This study, which utilized prospective calculated HEART scores, demonstrated that overall performance of the HEART score was reasonable. Specifically, our analysis showed that the rate of 30-day MACE was not affected by cocaine use as a risk factor. We would recommend clinicians to consider the HEART score for this patient group.
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Affiliation(s)
- Neeraja Murali
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Afrah Ali
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Robinson Okolo
- Research Associate Program, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Saad Pirzada
- Research Associate Program, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Benoit Stryckman
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Lauren Day
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel Lemkin
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mark Sutherland
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Zachary Dezman
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Quincy K Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Research Associate Program, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Program in Trauma, R Adam Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
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Lucyk SN. Acute Cardiovascular Toxicity of Cocaine. Can J Cardiol 2022; 38:1384-1394. [PMID: 35697321 DOI: 10.1016/j.cjca.2022.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/22/2022] [Accepted: 05/02/2022] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Scott N Lucyk
- Poison and Drug Information Service, Alberta Health Services, Calgary, Alberta, Canada; Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Section of Clinical Pharmacology and Toxicology, Alberta Health Services, Calgary, Alberta, Canada.
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Faramand Z, Martin-Gill C, Callaway C, Al-Zaiti S. Modified HEART score to optimize risk stratification in cocaine-associated chest pain. Am J Emerg Med 2021; 47:307-308. [PMID: 33494961 DOI: 10.1016/j.ajem.2021.01.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/11/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- Ziad Faramand
- Department of Acute & Tertiary Care Nursing, University of Pittsburgh, Pittsburgh, PA, USA; University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA.
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Clifton Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Salah Al-Zaiti
- Department of Acute & Tertiary Care Nursing, University of Pittsburgh, Pittsburgh, PA, USA; Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Division of Cardiology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Gresnigt FMJ, Gubbels NP, Riezebos RK. The current practice for cocaine-associated chest pain in the Netherlands. Toxicol Rep 2021; 8:23-27. [PMID: 33384944 PMCID: PMC7770504 DOI: 10.1016/j.toxrep.2020.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 12/08/2020] [Accepted: 12/10/2020] [Indexed: 12/25/2022] Open
Abstract
Introduction Cocaine is considered a cardiovascular risk factor, yet it is not included in the frequently used risk stratification scores. Moreover, many guidelines provide limited advice on how to diagnose and treat cocaine-associated chest pain (CACP). This study aimed to determine the current practice for CACP patients in emergency departments and coronary care units throughout the Netherlands. Methods An anonymous online questionnaire-based survey was conducted among Dutch emergency physicians and cardiologists between July 2015 and February 2016. The questionnaire was based on the American Heart Association CACP treatment algorithm. Results A total of 214 subjects were enrolled and completed the questionnaire. All responders considered cocaine use a risk factor for developing acute coronary syndrome (ACS), nevertheless 74.4 % of emergency physicians and 81.1 % of cardiologists do not always question chest pain patients about drug use. Of all responders, 73.6 % never perform toxicology screening. Most responders (60 %) observe patients with CACP according to the European Society of Cardiology ACS guideline, and 24.3 % give these patients ß-blockers. Conclusion The current practice for CACP patients in most emergency departments and coronary care units in the Netherlands is not in line with the AHA scientific statement. Emergency physicians and cardiologists should be advised to routinely question all chest pain patients on drug history and be aware that the risk stratifications scores are not validated for CACP. Despite the AHA scientific statement of 2008, many respondents utilize ß-blockers for CACP patients, which is supported by published evidence since the statement appeared.
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Affiliation(s)
- Femke M J Gresnigt
- Emergency Physician, Emergency Department, OLVG Hospital, Oosterpark 9, 1091AC, Amsterdam, the Netherlands
| | - Nanda P Gubbels
- Emergency Medicine Resident, Emergency Department, OLVG Hospital, Oosterpark 9, 1091AC, Amsterdam, the Netherlands
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