Original contribution
Coronary angiographic findings in patients with cocaine-associated chest pain

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Abstract

Patients who present to the Emergency Department (ED) with chest pain associated with cocaine use are a common problem. The incidence and predictors of underlying significant coronary disease in patients with and without myocardial infarction (MI) has not been well described. Patients who underwent coronary angiography within 5 weeks of an ED evaluation for cocaine-associated chest pain were studied. Significant disease was defined as ≥ 50% stenosis of a coronary artery or major branches or bypass graft. A total of 90 patients underwent coronary angiography. Significant disease was present in 45 (50%), with 1-vessel disease in 32%, 2-vessel disease in 10%, 3-vessel disease in 6%, with significant graft stenosis in 3%. Significant disease was present in 77% of patients with MI or troponin I elevations, compared to only 35% of patients without myonecrosis. Predictors of significant coronary disease included MI or troponin I elevations, prior MI, known coronary disease (prior MI or revascularization), and elevated cholesterol. Only 7 of the 39 patients (18%) without myonecrosis or a history of coronary disease had significant disease on angiography. In conclusion, significant disease is found in the majority of patients with cocaine-associated MI or troponin elevations. In contrast, only a minority of those without myonecrosis have significant coronary disease.

Introduction

The standard protocol for patients undergoing an ischemic evaluation typically includes coronary angiography in those with myocardial infarction (MI) and those in whom there is a high suspicion of coronary disease (1). In patients for whom there is a low suspicion of coronary disease after MI is excluded, stress testing is typically performed. In patients with cocaine-associated chest pain, the optimal diagnostic strategy has not been defined. In those without MI, the value of additional risk stratification is unclear, because only a small minority undergoes further diagnostic testing (2). Although cocaine-associated MI is often thought to result from coronary vasospasm, the incidence of underlying coronary disease in patients with MI has been relatively high (3). Thus, these patients may represent a select subgroup of patients after cocaine use. In this study, we report the results of coronary angiography performed in a cohort of patients who initially presented to the Emergency Department (ED) complaining of chest pain or who had symptoms consistent with myocardial ischemia associated with cocaine use.

Section snippets

Materials and methods

This study was performed at a 600-bed inner city hospital, which has approximately 85,000 Emergency Department visits a year. This study includes consecutive patients who underwent evaluation in the ED from June 1994 to January 2001 for symptoms consistent with myocardial ischemia that were associated with recent cocaine use, and who subsequently had coronary angiography within 5 weeks of the ED evaluation. Patients either acknowledged recent cocaine use or had a positive urine drug screen for

Results

From June 1994 to January 2001, 734 patients underwent evaluation for symptoms thought to be consistent with myocardial ischemia after cocaine use, of whom 90 underwent coronary angiography within 5 weeks of the ED evaluation. Demographic variables and cardiac risk factors are shown in Table 1. Thirty-two patients (36%) had evidence of prior coronary disease, which consisted of prior MI in 29 (32%), coronary artery bypass surgery in 3 (4%) and percutaneous coronary intervention (PCI) in 9

Discussion

Our data show that underlying coronary disease is common in patients with cocaine-associated myocardial infarction. In contrast, in patients without evidence of myocardial necrosis, significant disease was less common and was infrequent in those without a history of MI or coronary disease.

Various etiologies for cocaine-associated MI have been proposed. In vivo studies have shown that acute cocaine use causes significant coronary artery spasm, especially in combination with tobacco use 6, 7.

Conclusions

The majority of patients who have cocaine-associated MI have significant coronary disease. In contrast, patients without myonecrosis have a low incidence of disease, and therefore coronary angiography should not be the routine first test to evaluate for ischemia in these patients.

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    Presented in part at the 50th Annual Scientific Sessions of the American College of Cardiology, Orlando, Florida, March, 2001

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