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Hassan MA, Grewal N, Nepaul D. A Case of Mitral Valve Infective Endocarditis and Atrial Fibrillation Complicated by Hemorrhagic Stroke: A Challenging Clinical Scenario and Approach to Management. Cureus 2023; 15:e41634. [PMID: 37575781 PMCID: PMC10412743 DOI: 10.7759/cureus.41634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/10/2023] [Indexed: 08/15/2023] Open
Abstract
This case report presents a rare and intricate clinical scenario involving a 58-year-old male with a history of hypertension, intravenous drug use (IVDU), and cocaine abuse. The patient presented with profound hypotension and symptoms suggestive of impending shock. Septic workup revealed Staphylococcus aureus in all four blood culture bottles, confirming a diagnosis of infective endocarditis (IE). Transthoracic echocardiography demonstrated a large vegetation measuring 1.9x1.7 cm on the mitral valve. Additionally, the patient exhibited non-ST segment elevated myocardial infarction (NSTEMI) type II in the setting of cocaine use, atrial fibrillation, and therapeutic anticoagulation. Subsequent imaging studies raised concerns regarding hemorrhagic stroke. A multidisciplinary team comprising cardiology, cardiothoracic surgery, infectious disease, and neurology collaborated to develop an optimal management strategy. Considering the high-risk features of the IE and the need to address the hemorrhagic stroke, anticoagulation was temporarily halted, and the patient was transferred for urgent mitral valve replacement surgery. This case highlights the complex interplay between substance abuse, cardiovascular complications, IE, and neurological events, underscoring the challenges encountered in managing such patients.
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Affiliation(s)
- Mubariz A Hassan
- Internal Medicine, Howard University Hospital, Washington, D.C., USA
| | - Niyati Grewal
- Internal Medicine, Howard University Hospital, Washington, D.C., USA
| | - Daniel Nepaul
- Cardiovascular Disease, Howard University Hospital, Washington, D.C., USA
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Arora S, Jaswaney R, Jani C, Zuzek Z, Thakkar S, Patel M, Panaich SS, Tripathi B, Arora N, Josephson R, Osman MN, Hoit BD, Zidar D, Shishehbor MH. Invasive Approaches in the Management of Cocaine-Associated Non-ST-Segment Elevation Myocardial Infarction. JACC Cardiovasc Interv 2021; 14:623-636. [PMID: 33736770 DOI: 10.1016/j.jcin.2021.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/30/2020] [Accepted: 01/05/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to determine the impact of invasive approaches and revascularization in patients with cocaine-associated non-ST-segment elevation myocardial infarction (NSTEMI). BACKGROUND The role of invasive approaches in cocaine-associated NSTEMI is uncertain. METHODS This retrospective cohort study identified 3,735 patients with NSTEMI and history of cocaine use from the Nationwide Readmissions Database from 2016 to 2017. Invasive approaches were defined as coronary angiography, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). Revascularization was defined as PCI and CABG. The primary efficacy outcome was major adverse cardiac events (MACE), and the primary safety outcome was emergent revascularization. Nonadherence was identified using appropriate International Classification of Diseases-Tenth Revision codes. Two propensity-matched cohorts were generated (noninvasive vs. invasive and noninvasive vs. revascularization) through multivariate logistic regression. RESULTS In the propensity score-matched cohorts, an invasive approach (hazard ratio [HR]: 0.72; 95% confidence interval [CI]: 0.56 to 0.92; p = 0.008) and revascularization (HR: 0.54; 95% CI: 0.40 to 0.73; p < 0.001) (compared with a noninvasive approach) were associated with a lower rate of MACE, without an increase in emergent revascularization. On stratification, PCI and CABG individually were associated with a lower rate of MACE. Emergent revascularization was increased with PCI (HR: 1.78; 95% CI: 1.12 to 2.81; p = 0.014) but not with CABG. Nonadherent patients after PCI and CABG did not have significant difference in rate of MACE. PCI in nonadherent patients was associated with an increase in emergent revascularization (HR: 4.45; 95% CI: 2.07 to 9.57; p < 0.001). CONCLUSIONS Invasive approaches and revascularization for cocaine-associated NSTEMI are associated with lower morbidity. A history of medical nonadherence was not associated with a difference in morbidity but was associated with an increased risk for emergent revascularization with PCI.
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Affiliation(s)
- Shilpkumar Arora
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Rahul Jaswaney
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Chinmay Jani
- Mount Auburn Hospital-Harvard Medical School, Cambridge, Massachusetts, USA
| | - Zachary Zuzek
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Mohini Patel
- Boston University School of Public Health, Boston, Massachusetts, USA
| | | | | | | | - Richard Josephson
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Mohammed Najeeb Osman
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Brian D Hoit
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - David Zidar
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Mehdi H Shishehbor
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, 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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Carrillo X, Vilalta V, Cediel G, Fernandez-Nofrerias E, Rodriguez-Leor O, Mauri J, Abdul Jawad-Altisent O, Garcia-Garcia C, Serra J, Bayes-Genis A. Trends in prevalence and outcomes of acute coronary syndrome associated with cocaine consumption: The RUTI-cocaine study. Int J Cardiol 2019; 283:23-27. [DOI: 10.1016/j.ijcard.2018.12.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/08/2018] [Accepted: 12/06/2018] [Indexed: 11/15/2022]
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Maza-Quiroga R, García-Marchena N, Romero-Sanchiz P, Barrios V, Pedraz M, Serrano A, Nogueira-Arjona R, Ruiz JJ, Soria M, Campos R, Chowen JA, Argente J, Torrens M, López-Gallardo M, Marco EM, Rodríguez de Fonseca F, Pavón FJ, Araos P. Evaluation of plasma cytokines in patients with cocaine use disorders in abstinence identifies transforming growth factor alpha (TGFα) as a potential biomarker of consumption and dual diagnosis. PeerJ 2017; 5:e3926. [PMID: 29038767 PMCID: PMC5641428 DOI: 10.7717/peerj.3926] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 09/24/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Cocaine use disorder (CUD) is a complex health condition, especially when it is accompanied by comorbid psychiatric disorders (dual diagnosis). Dual diagnosis is associated with difficulties in the stratification and treatment of patients. One of the major challenges in clinical practice of addiction psychiatry is the lack of objective biological markers that indicate the degree of consumption, severity of addiction, level of toxicity and response to treatment in patients with CUD. These potential biomarkers would be fundamental players in the diagnosis, stratification, prognosis and therapeutic orientation in addiction. Due to growing evidence of the involvement of the immune system in addiction and psychiatric disorders, we tested the hypothesis that patients with CUD in abstinence might have altered circulating levels of signaling proteins related to systemic inflammation. METHODS The study was designed as a cross-sectional study of CUD treatment-seeking patients. These patients were recruited from outpatient programs in the province of Malaga (Spain). The study was performed with a total of 160 white Caucasian subjects, who were divided into the following groups: patients diagnosed with CUD in abstinence (N = 79, cocaine group) and matched control subjects (N = 81, control group). Participants were clinically evaluated with the diagnostic interview PRISM according to the DSM-IV-TR, and blood samples were collected for the determination of chemokine C-C motif ligand 11 (CCL11, eotaxin-1), interferon gamma (IFNγ), interleukin-4 (IL-4), interleukin-8 (IL-8), interleukin-17α (IL-17α), macrophage inflammatory protein 1α (MIP-1α) and transforming growth factor α (TGFα) levels in the plasma. Clinical and biochemical data were analyzed in order to find relationships between variables. RESULTS While 57% of patients with CUD were diagnosed with dual diagnosis, approximately 73% of patients had other substance use disorders. Cocaine patients displayed greater cocaine symptom severity when they were diagnosed with psychiatric comorbidity. Regarding inflammatory factors, we observed significantly lower plasma levels of IL-17α (p < 0.001), MIP-1α (p < 0.001) and TGFα (p < 0.05) in the cocaine group compared with the levels in the control group. Finally, there was a significant primary effect of dual diagnosis on the plasma concentrations of TGFα (p < 0.05) in the cocaine group, and these levels were lower in patients with dual diagnoses. DISCUSSION IL-17α, MIP-1α and TGFα levels are different between the cocaine and control groups, and TGFα levels facilitate the identification of patients with dual diagnosis. Because TGFα reduction is associated with enhanced responses to cocaine in preclinical models, we propose TGFα as a potential biomarker of complex CUD in humans.
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Affiliation(s)
- Rosa Maza-Quiroga
- Hospital Regional Universitario de Málaga, Unidad de Gestión Clínica de Salud Mental, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - Nuria García-Marchena
- Hospital Regional Universitario de Málaga, Unidad de Gestión Clínica de Salud Mental, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - Pablo Romero-Sanchiz
- Hospital Regional Universitario de Málaga, Unidad de Gestión Clínica de Salud Mental, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - Vicente Barrios
- Department of Endocrinology, Hospital Universitario Niño Jesús, Madrid, Spain
| | - María Pedraz
- Hospital Regional Universitario de Málaga, Unidad de Gestión Clínica de Salud Mental, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - Antonia Serrano
- Hospital Regional Universitario de Málaga, Unidad de Gestión Clínica de Salud Mental, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - Raquel Nogueira-Arjona
- Hospital Regional Universitario de Málaga, Unidad de Gestión Clínica de Salud Mental, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - Juan Jesus Ruiz
- Diputación de Málaga, Centro Provincial de Drogodependencias, Málaga, Spain
| | - Maribel Soria
- Diputación de Málaga, Centro Provincial de Drogodependencias, Málaga, Spain
| | - Rafael Campos
- Diputación de Málaga, Centro Provincial de Drogodependencias, Málaga, Spain
| | - Julie Ann Chowen
- Department of Endocrinology, Hospital Universitario Niño Jesús, Madrid, Spain
| | - Jesus Argente
- Department of Endocrinology, Hospital Universitario Niño Jesús, Madrid, Spain
| | - Marta Torrens
- Institut de Neuropsiquiatria i Addiccions (INAD) del Parc de Salut Mar, Barcelona, Spain
| | | | - Eva María Marco
- Department of Physiology II Faculty of Biology, Universidad Complutense de Madrid, Madrid, Spain
| | - Fernando Rodríguez de Fonseca
- Hospital Regional Universitario de Málaga, Unidad de Gestión Clínica de Salud Mental, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - Francisco Javier Pavón
- Hospital Regional Universitario de Málaga, Unidad de Gestión Clínica de Salud Mental, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - Pedro Araos
- Department of Physiology II Faculty of Biology, Universidad Complutense de Madrid, Madrid, Spain
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Beta-blockers and Cocaine-Associated ST-Segment Elevation Myocardial Infarction in an Inner-City Community. Am J Cardiol 2017; 120:e81. [PMID: 28087051 DOI: 10.1016/j.amjcard.2016.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 12/20/2016] [Accepted: 12/20/2016] [Indexed: 11/22/2022]
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Gundareddy VP, Maruthur NM, Chibungu A, Bollampally P, Landis R, Eid SM. Association Between Radiologic Incidental Findings and Resource Utilization in Patients Admitted With Chest Pain in an Urban Medical Center. J Hosp Med 2017; 12:323-328. [PMID: 28459900 DOI: 10.12788/jhm.2722] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Increasing use of testing among hospitalized patients has resulted in an increase in radiologic incidental findings (IFs), which challenge the provision of high-value care in the hospital setting. OBJECTIVE To understand impact of radiologic incidental findings on resource utilization in patients hospitalized with chest pain. DESIGN Retrospective observational cross sectional study. SETTING Academic medical center. PARTICIPANTS Adult patients hospitalized with principal diagnosis of chest pain. MEASUREMENTS Demographic, imaging, and length of stay (LOS) data were abstracted from the medical charts. We used multiple logistic regression to evaluate factors associated with radiologic IFs and negative binomial regression to evaluate the association between radiologic IFs and LOS. RESULTS 1811 consecutive admissions with chest pain were analyzed retrospectively over a period of 24 months; 376 patients were included in the study after exclusion criteria were applied and readmissions removed. Of these, 197 patients (52%) had 364 new radiologic IFs on imaging; most IFs were of minor (50%) or moderate clinical significance (42%), with only 7% of major significance. Odds of finding radiologic IFs increased with age (adjusted odds ratio, 1.04; 95% confidence interval [CI], 1.01-1.06) and was associated with a 26% increase in LOS (adjusted incidence rate ratio, 1.26; 95% CI, 1.07-1.49). CONCLUSION Radiologic IFs were very common among patients hospitalized with chest pain of suspected cardiac origin and independently associated with an increase in the LOS. Interventions to address radiologic IFs may reduce LOS and, thereby, support high-value care. Journal of Hospital Medicine 2017;12:323-328.
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Affiliation(s)
- Venkat P Gundareddy
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nisa M Maruthur
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore MD; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD
| | - Abednego Chibungu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Regina Landis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shaker M Eid
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Richards JR, Hollander JE, Ramoska EA, Fareed FN, Sand IC, Izquierdo Gómez MM, Lange RA. β-Blockers, Cocaine, and the Unopposed α-Stimulation Phenomenon. J Cardiovasc Pharmacol Ther 2016; 22:239-249. [PMID: 28399647 DOI: 10.1177/1074248416681644] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Cocaine abuse remains a significant worldwide health problem. Patients with cardiovascular toxicity from cocaine abuse frequently present to the emergency department for treatment. These patients may be tachycardic, hypertensive, agitated, and have chest pain. Several pharmacological options exist for treatment of cocaine-induced cardiovascular toxicity. For the past 3 decades, the phenomenon of unopposed α-stimulation after β-blocker use in cocaine-positive patients has been cited as an absolute contraindication, despite limited and inconsistent clinical evidence. In this review, the authors of the original studies, case reports, and systematic review in which unopposed α-stimulation was believed to be a factor investigate the pathophysiology, pharmacology, and published evidence behind the unopposed α-stimulation phenomenon. We also investigate other potential explanations for unopposed α-stimulation, including the unique and deleterious pharmacologic properties of cocaine in the absence of β-blockers. The safety and efficacy of the mixed β-/α-blockers labetalol and carvedilol are also discussed in relation to unopposed α-stimulation.
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Affiliation(s)
- John R Richards
- 1 Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA, USA
| | - Judd E Hollander
- 2 Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Edward A Ramoska
- 3 Department of Emergency Medicine, Drexel University, Philadelphia, PA, USA
| | - Fareed N Fareed
- 4 Emergency Medical Associates, EmCare Partners Group, Parsippany, NJ, USA
| | | | | | - Richard A Lange
- 7 Division of Cardiology, Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
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