Observing, Not Admitting, Patients with Cocaine-Related Chest Pain
The “this is your brain on drugs” ads have done a lot to spread the message about the harmful effects of drugs, including cocaine, to the brain. But the effects of cocaine use on the heart are less well known, at least to the general public.
In fact, cocaine use can have devastating effects on cardiovascular health. For example, the risk of having a ]]>heart attack]]> is an astonishing 24 times higher than normal in the first hour after cocaine is used. And cocaine users have a lifetime risk of nonfatal heart attack that is seven times that of nonusers. This is true even though the majority of cocaine users have few, if any, other risk factors for heart disease.
And yet the vast majority of cocaine-induced chest pain is not due to heart attack. Despite this, a large number of patients who come to the emergency room with cocaine-induced chest pain are admitted to the hospital, for an average of three days.
While 12-hour observation periods have been proven safe and effective for patients who are at low risk for cardiovascular events and who have not recently used cocaine, no criteria have been established that allow for the safe and rapid discharge of patients with cocaine-associated chest pain.
In a study published in the February 6, 2003 New England Journal of Medicine , researchers found that patients with cocaine-associated chest pain, who were identified as being at low risk for a heart attack, could be safely released after a nine to twelve hour observation period. Further, these patients had low risk of death or heart attack in the 30 days following discharge.
About the Study
Scientists evaluated 344 patients who came into the emergency room with cocaine-associated chest pain between January 1, 1998 and January 1, 2000. Cocaine use was determined through a combination of patient reporting and toxicologic urine screening. Based on their age, the presence or absence of other coronary risk factors, and the results of an electrocardiogram (EKG) and other diagnostic tests, the patients were categorized as being high-risk or low-risk for a heart attack.
Of the 344 patients, 42 patients were determined to be high risk, and were immediately admitted to the hospital. The remaining 302 patients, who were at low-to-intermediate risk, comprised the study cohort.
The study participants entered the observation unit where they were watched closely for signs of serious heart trouble. In addition to continuous ]]>EKG]]> monitoring, physicians obtained the levels of cardiac troponin, a protein marker that becomes elevated when there is heart damage from any cause including cocaine use. The patients were given aspirin, nitrates, or other interventional medications as deemed necessary.
After nine hours of observation, all patients were evaluated by a cardiologist. Patients who did not appear to be at risk for a cardiac event were discharged from the observation unit within twelve hours, with written information about the risks of cocaine use.
After at least 30 days from discharge, the researchers followed up to find out if the patients had experienced recurrent chest pain, subsequent heart attack, or death.
At 30 days after discharge, none of the patients had died from cardiovascular causes. Four of the patients, or 1.6%, had a nonfatal heart attack during the 30-day follow up, but all of these patients had continued to use cocaine after discharge. In addition, all four of these patients had at least two additional cardiac risk factors.
How Does This Affect You?
While successful protocols like this are useful for emergency room physicians and can provide important cost-savings without putting any lives at risk, the real message from this study is that cocaine is a serious drug that kills otherwise healthy, young people. In their efforts to change the behavior of current and would-be users, health advocates should use studies like this to point out the extreme short-term dangers of cocaine.
This protocol raises another important point. Emergency room personnel need accurate information regarding drug use when making critical decisions about the care of patients. Previous studies have shown that almost one-third of cocaine users in the emergency room lie about their drug use. Toxicologic urine screening, as performed in this study, can help, but without a high index of suspicion by physicians, cocaine-induced chest pain may not be recognized as such, and may be dismissed as inconsequential in an otherwise healthy patient.
Finally, the four patients in this study who had a heart attack during the follow up period had continued to use cocaine after discharge. This highlights the need for patient education and the availability and accessibility of drug treatment programs.
National Heart, Lung, and Blood Institute
National Institutes of Health
National Institute on Drug Abuse
National Institutes of Health
Kloner RA and SH Rezkalla. Cocaine and the heart. NEJM . [Perspective]. 2003;348:487-488.
Weber JE, Shofer FS, et al. Validation of a brief observation period for patients with cocaine-associated chest pain. NEJM . 2003; 348:510-517.
Last reviewed Feb 6, 2003 by ]]>Richard Glickman-Simon, MD]]>
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