Coronary computerized tomography angiography for rapid discharge of low-risk patients with cocaine-associated chest pain

被引：14
作者：
Walsh K.M. [1 ]
Chang A.M. [1 ]
Perrone J. [1 ]
McCusker C.M. [1 ]
Shofer F.S. [1 ]
Collin M.J. [1 ]
Litt H.I. [2 ]
Hollander J.E. [1 ]
机构：
[1] Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
[2] Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA
来源：
Journal of Medical Toxicology | 2009年 / 5卷 / 3期
关键词：
Acute coronary syndrome; Chest pain; Cocaine; Complications; Computerized tomography; Observation units; Risk stratification;
D O I：
10.1007/BF03161220
中图分类号：
学科分类号：
摘要：
Background: Most patients presenting to emergency departments (EDs) with cocaine-associated chest pain are admitted for at least 12 hours and receive a "rule out acute coronary syndrome" protocol, often with noninvasive testing prior to discharge. In patients without cocaine use, coronary computerized tomography angiography (CTA) has been shown to be useful for identifying a group of patients at low risk for cardiac events who can be safely discharged. It is unclear whether a coronary CTA strategy would be efficacious in cocaine-associated chest pain, as coronary vasospasm may account for some of the ischemia. We studied whether a negative coronary CTA in patients with cocaine-associated chest pain could identify a subset safe for discharge. Methods: We prospectively evaluated the safety of coronary CTA for low-risk patients who presented to the ED with cocaineassociated chest pain (self-reported or positive urine test). Consecutive patients received either immediate coronary CTA in the ED (without serial markers) or underwent coronary CTA after a brief observation period with serial cardiac marker measurements. Patients with negative coronary CTA (maximal stenosis less than 50%) were discharged. The main outcome was 30-day cardiovascular death or myocardial infarction. Results: A total of 59 patients with cocaine-associated chest pain were evaluated. Patients had a mean age of 45.6 ± 6.6 yrs and were 86% black, 66% male. Seventy-nine percent had a normal or nonspecific ECG and 85% had a TIMI score <2. Twenty patients received coronary CTA immediately in the ED, 18 of whom were discharged following CTA (90%). Thirty-nine received coronary CTA after a brief observation period, with 37 discharged home following CTA (95%). Six patients had coronary stenosis ≥50%. During the 30-day follow-up period, no patients died of a cardiovascular event (0%; 95% CI, 0-6.1%) and no patient sustained a nonfatal myocardial infarction (0%; 95% CI, 0-6.1%). Conclusions: Although cocaine-associated myocardial ischemia can result from coronary vasoconstriction, patients with cocaineassociated chest pain, a non-ischemic ECG, and a TIMI risk score <2 may be safely discharged from the ED after a negative coronary CTA with a low risk of 30-day adverse events.
引用
收藏
页码：111 / 119
页数：8
相关论文
共 59 条
  • [41] Hollander J.E., Hoffman R.S., Cocaine-induced myocardial infarction: An analysis and review of the literature, J Emerg Med, 10, pp. 169-177, (1992)
  • [42] Kumar K., Holden W.E., Drug-induced pulmonary vascular disease: Mechanisms and clinical patterns, West J Med, 145, pp. 343-349, (1986)
  • [43] Lange R.A., Cigarroa R.G., Yancy C.W., Et al., Cocaine-induced coronary artery vasoconstriction, N Eng J Med, 321, pp. 1557-1562, (1989)
  • [44] Togna G., Tempesta E., Togna A.R., Et al., Platelet responsiveness and biosynthesis of thromboxane and prostacyclin in response to in vitro cocaine treatment, Haemostasis, 15, pp. 100-107, (1985)
  • [45] Isner J.M., Estes M., Thompson P.D., Et al., Acute cardiac events temporally related to cocaine abuse, N Eng J Med, 315, pp. 1438-1443, (1985)
  • [46] Stenberg R.G., Winniford M.D., Hillis L.D., Et al., Simultaneous acute thrombosis of two major coronary arteries following intravenous cocaine use, Arch Pathol Lab Med, 113, pp. 521-524, (1989)
  • [47] Moliterno D.J., Lange R.A., Gerard R.D., Et al., Influence of intranasal cocaine on plasma constituents associated with endogenous thrombosis and thrombolysis, Am J Med, 96, pp. 492-496, (1994)
  • [48] Weber J.E., Hollander J.E., Murphy S.A., Quantitative comparison of coronary artery flow and myocardial perfusion in patients with acute myocardial infarction in the presence and absence of recent cocaine use, J Thromb Thrombolysis, 14, 3, pp. 239-245, (2002)
  • [49] Brogan III. W.C., Lange R.A., Glamann B., Et al., Recurrent coronary vasoconstriction caused by intranasal cocaine: Possible role for metabolites, Ann Intern Med, 116, pp. 556-561, (1992)
  • [50] McCord J., Hani J., Hollander J.E., Et al., Management of cocaine-associated chest pain and myocardial infarction: A scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology, Circulation, 117, pp. 1897-1907, (2008)
123456