12-hour protocol safe for cocaine-associated chest pain
The Journal of Family Practice. 2003 June;52(6):431-454
June 1, 2003|The Journal of Family Practice
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- BACKGROUND: In the first hour after cocaine use, there is a 24-fold increase in the risk of sustaining MI. In 2000, over $83 million was spent on hospitalization for cocaine-associated chest pain.
- POPULATION STUDIED: The authors enrolled a total of 302 subjects with acute onset chest pain. The mean age for subjects was 37.6 years; 66% were male, and 70% were African-American.
- STUDY DESIGN AND VALIDITY: From January 1, 1998, to January 1, 2000, the authors enrolled consecutive subjects with cocaine-associated chest pain in a longitudinal cohort study. Investigators questioned subjects regarding the route and timing of cocaine use and classified the ECGs according to the degree of ischemia present.
- OUTCOMES MEASURED: The outcomes measured at 30 days included death from cardiovascular causes, ventricular dysrhythmias, nonfatal MI, recurrent chest pain, and recurrent cocaine use.
- RESULTS: Outcome data were available for 300 of the 302 subjects. There were no deaths from cardiovascular causes—the 2 individuals who could not be reached for follow-up were not listed on the National Death Registry.
PRACTICE RECOMMENDATIONS
A 12-hour emergency department observation period is safe for patients with cocaine-associated chest pain, provided they have symptoms consistent with low-to-intermediate likelihood of unstable angina according to the Braunwald classification, and normal serial troponin I levels and cardiogram.
Patients with traditional cardiac risk factors should undergo cardiac stress testing within 2 weeks following the chest pain event, as atherosclerosis enhances the vasoconstrictive effects of cocaine. All patients should be referred for substance abuse counseling, as recurrent cocaine use was associated with subsequent nonfatal myocardial infarction (MI).
