Cocaine-inducedCocaine-induced chest painchest painFocus on Acute coronary Focus on Acute coronary

syndromessyndromes

Daniel Brouillard, R3Daniel Brouillard, R3McGill Emergency MedicineMcGill Emergency Medicine

December 12 2001December 12 2001

ObjectivesObjectivesObjectivesObjectives

What is the prevalence of ACS/AMI in cocaine users?What is the prevalence of ACS/AMI in cocaine users?

What is the role of the EKG in the diagnosis of ACS in this What is the role of the EKG in the diagnosis of ACS in this particular patient population?particular patient population?

What is the most beneficial approach to management based on What is the most beneficial approach to management based on the current litterature?the current litterature?

What is the role of reperfusion therapy in these patients?What is the role of reperfusion therapy in these patients?

What is the prevalence of ACS/AMI in cocaine users?What is the prevalence of ACS/AMI in cocaine users?

What is the role of the EKG in the diagnosis of ACS in this What is the role of the EKG in the diagnosis of ACS in this particular patient population?particular patient population?

What is the most beneficial approach to management based on What is the most beneficial approach to management based on the current litterature?the current litterature?

What is the role of reperfusion therapy in these patients?What is the role of reperfusion therapy in these patients?

PlanPlanPlanPlan

1)1) CocaineCocaine

2)2) Cocaine associated-C/P Cocaine associated-C/P

3)3) Cocaine-related myocardial ischemia Cocaine-related myocardial ischemia

1)1) CocaineCocaine

2)2) Cocaine associated-C/P Cocaine associated-C/P

3)3) Cocaine-related myocardial ischemia Cocaine-related myocardial ischemia

CocaineCocaineCocaineCocaine

Erythroxylon cocaErythroxylon coca Benzoylmethylecgonine Benzoylmethylecgonine

(cocaine)(cocaine) Primarly grown in Primarly grown in

South AmericaSouth America Hydrochloride saltHydrochloride salt « free base »« free base »

Erythroxylon cocaErythroxylon coca Benzoylmethylecgonine Benzoylmethylecgonine

(cocaine)(cocaine) Primarly grown in Primarly grown in

South AmericaSouth America Hydrochloride saltHydrochloride salt « free base »« free base »

HistoryHistoryHistoryHistory 3000 B.C.3000 B.C. Coca leaves are chewed in South America, Coca leaves are chewed in South America,

believed to be a gift from God.believed to be a gift from God. 1400’s 1400’s Coca plantations operated by Incas.Coca plantations operated by Incas. 1662 1662 First indepedent mention of coca in the English First indepedent mention of coca in the English

litterature: « A legend of Coca » by Abraham Coley.litterature: « A legend of Coca » by Abraham Coley. 18501850 Coca tinctures used in throat surgery. Coca tinctures used in throat surgery. 18551855 Cocaine is first extracted from coca leaves. Cocaine is first extracted from coca leaves. 1870 1870 Vin Mariani is for sale in Europe, in contains 6mg of Vin Mariani is for sale in Europe, in contains 6mg of

cocaine per ounce of wine. cocaine per ounce of wine.

3000 B.C.3000 B.C. Coca leaves are chewed in South America, Coca leaves are chewed in South America, believed to be a gift from God.believed to be a gift from God.

1400’s 1400’s Coca plantations operated by Incas.Coca plantations operated by Incas. 1662 1662 First indepedent mention of coca in the English First indepedent mention of coca in the English

litterature: « A legend of Coca » by Abraham Coley.litterature: « A legend of Coca » by Abraham Coley. 18501850 Coca tinctures used in throat surgery. Coca tinctures used in throat surgery. 18551855 Cocaine is first extracted from coca leaves. Cocaine is first extracted from coca leaves. 1870 1870 Vin Mariani is for sale in Europe, in contains 6mg of Vin Mariani is for sale in Europe, in contains 6mg of

cocaine per ounce of wine. cocaine per ounce of wine.

History (continued)History (continued)History (continued)History (continued)

1884 1884 Sigmund Freud publishes « On Coca » in witch he Sigmund Freud publishes « On Coca » in witch he recommends the use of cocaine in the treatment of various recommends the use of cocaine in the treatment of various conditions.conditions.

1886 1886 Introduction of Coca-Cola: contains cocaine syrup. Introduction of Coca-Cola: contains cocaine syrup. 18951895 First cases of associated deaths reported in the Lancet. First cases of associated deaths reported in the Lancet. 19121912 5000 cocaine related fatalities per year 5000 cocaine related fatalities per year 19141914 Harrison’s Narcotics Act Harrison’s Narcotics Act 1970’s -80’s1970’s -80’s Days of Glory Days of Glory Mid-80’sMid-80’s Freebase cocaine( crack) Freebase cocaine( crack)

1884 1884 Sigmund Freud publishes « On Coca » in witch he Sigmund Freud publishes « On Coca » in witch he recommends the use of cocaine in the treatment of various recommends the use of cocaine in the treatment of various conditions.conditions.

1886 1886 Introduction of Coca-Cola: contains cocaine syrup. Introduction of Coca-Cola: contains cocaine syrup. 18951895 First cases of associated deaths reported in the Lancet. First cases of associated deaths reported in the Lancet. 19121912 5000 cocaine related fatalities per year 5000 cocaine related fatalities per year 19141914 Harrison’s Narcotics Act Harrison’s Narcotics Act 1970’s -80’s1970’s -80’s Days of Glory Days of Glory Mid-80’sMid-80’s Freebase cocaine( crack) Freebase cocaine( crack)

Presentation and pharmacologyPresentation and pharmacologyPresentation and pharmacologyPresentation and pharmacology

.. Erythroxylon CocaErythroxylon Coca

Cocaine saltCocaine salt « freebase » cocaine« freebase » cocaine

SnortedSnortedIngestedIngestedInjectedInjected

Heat stableHeat stableSmokedSmoked

Onset and duration of actionOnset and duration of actionOnset and duration of actionOnset and duration of action

ROUTEROUTE ONSETONSET PEAK (min)PEAK (min)DURATION DURATION (min) (min)

Inhalation or Inhalation or IvIv

SecondsSeconds 3-53-5 15-3015-30

InsufflationInsufflation1-3 min1-3 min 20-3020-30 60-9060-90

GIGIVariableVariable 60-9060-90 Over 180Over 180

EffectsEffectsEffectsEffects

1) Sodium channel 1) Sodium channel blocking properties blocking properties (Quinidine-Like)(Quinidine-Like)

2) Systemically, blocks the 2) Systemically, blocks the re-uptake of amines in re-uptake of amines in the synapse.the synapse.

1) Sodium channel 1) Sodium channel blocking properties blocking properties (Quinidine-Like)(Quinidine-Like)

2) Systemically, blocks the 2) Systemically, blocks the re-uptake of amines in re-uptake of amines in the synapse.the synapse.

ExcretionExcretionExcretionExcretion

Metabolised by liver and plasma esteraseMetabolised by liver and plasma esterase Ecgonyl methyl ester (30-50%)Ecgonyl methyl ester (30-50%) Benzylecgonine (40%)Benzylecgonine (40%)

Detection possible in urineDetection possible in urine

- Free cocaine : 6h- Free cocaine : 6h

- Benzylecgonine : up to 72 h.- Benzylecgonine : up to 72 h.

Metabolised by liver and plasma esteraseMetabolised by liver and plasma esterase Ecgonyl methyl ester (30-50%)Ecgonyl methyl ester (30-50%) Benzylecgonine (40%)Benzylecgonine (40%)

Detection possible in urineDetection possible in urine

- Free cocaine : 6h- Free cocaine : 6h

- Benzylecgonine : up to 72 h.- Benzylecgonine : up to 72 h.

CocaethyleneCocaethyleneCocaethyleneCocaethylene

2 substances often consummed together2 substances often consummed together Product of combination of cocaine and ET-OH Product of combination of cocaine and ET-OH

in the liver.in the liver. Dose related myocardial depression in dogs.Dose related myocardial depression in dogs. Longer half lifeLonger half life Could account for delayed presentation.Could account for delayed presentation.

2 substances often consummed together2 substances often consummed together Product of combination of cocaine and ET-OH Product of combination of cocaine and ET-OH

in the liver.in the liver. Dose related myocardial depression in dogs.Dose related myocardial depression in dogs. Longer half lifeLonger half life Could account for delayed presentation.Could account for delayed presentation.

Part IIPart IIPart IIPart II

Cocaine and peopleCocaine and peopleCocaine and peopleCocaine and people

30 million American at least one time users30 million American at least one time users 5 million current users5 million current users 160,000 visits per year in the USA160,000 visits per year in the USA

Statistiques Canada 1994: close to 2% of Statistiques Canada 1994: close to 2% of Canadian population are current usersCanadian population are current users

30 million American at least one time users30 million American at least one time users 5 million current users5 million current users 160,000 visits per year in the USA160,000 visits per year in the USA

Statistiques Canada 1994: close to 2% of Statistiques Canada 1994: close to 2% of Canadian population are current usersCanadian population are current users

Prevalence-QuestionsPrevalence-QuestionsPrevalence-QuestionsPrevalence-Questions

In cocaine users who present to the ED, how In cocaine users who present to the ED, how many will have a major complaint of C/P ?many will have a major complaint of C/P ?

How many of these patients have ACS ?How many of these patients have ACS ?

How many of these patients have AMI ?How many of these patients have AMI ?

In cocaine users who present to the ED, how In cocaine users who present to the ED, how many will have a major complaint of C/P ?many will have a major complaint of C/P ?

How many of these patients have ACS ?How many of these patients have ACS ?

How many of these patients have AMI ?How many of these patients have AMI ?

Hollander and al. Annals of Hollander and al. Annals of emergency medicine 1994emergency medicine 1994

Hollander and al. Annals of Hollander and al. Annals of emergency medicine 1994emergency medicine 1994

Prevalence of cocaine use in patients older Prevalence of cocaine use in patients older then 18 y presenting with C/Pthen 18 y presenting with C/P

359 patients359 patients Anonymous urine collection on everybodyAnonymous urine collection on everybody Found 20 % prevalence in urban areaFound 20 % prevalence in urban area Prevalence of 7% at the rural sitesPrevalence of 7% at the rural sites 28% of positives denied use when questioned28% of positives denied use when questioned

Prevalence of cocaine use in patients older Prevalence of cocaine use in patients older then 18 y presenting with C/Pthen 18 y presenting with C/P

359 patients359 patients Anonymous urine collection on everybodyAnonymous urine collection on everybody Found 20 % prevalence in urban areaFound 20 % prevalence in urban area Prevalence of 7% at the rural sitesPrevalence of 7% at the rural sites 28% of positives denied use when questioned28% of positives denied use when questioned

Rich, Annals of EM, June 1991Rich, Annals of EM, June 1991« Cocaine related Symptoms in patients presenting « Cocaine related Symptoms in patients presenting

to the ED »to the ED »

Rich, Annals of EM, June 1991Rich, Annals of EM, June 1991« Cocaine related Symptoms in patients presenting « Cocaine related Symptoms in patients presenting

to the ED »to the ED » 146 patients 146 patients Retrospective chart reviewRetrospective chart review Overall prevalence 16% for C/P (23 patients)Overall prevalence 16% for C/P (23 patients) Total of 3 patients admittedTotal of 3 patients admitted Stronger association with nasal route (11/23)Stronger association with nasal route (11/23)

146 patients 146 patients Retrospective chart reviewRetrospective chart review Overall prevalence 16% for C/P (23 patients)Overall prevalence 16% for C/P (23 patients) Total of 3 patients admittedTotal of 3 patients admitted Stronger association with nasal route (11/23)Stronger association with nasal route (11/23)

Brody, Am. Journal of medicine, 1990Brody, Am. Journal of medicine, 1990« Cocaine-related medical problems »« Cocaine-related medical problems »

Brody, Am. Journal of medicine, 1990Brody, Am. Journal of medicine, 1990« Cocaine-related medical problems »« Cocaine-related medical problems »

233 patients233 patients Retrospective chart reviewRetrospective chart review 40% prevalence of C/P40% prevalence of C/P Most had acute complaints(3 hMost had acute complaints(3 h<)<) Overall mortality 1%Overall mortality 1%

233 patients233 patients Retrospective chart reviewRetrospective chart review 40% prevalence of C/P40% prevalence of C/P Most had acute complaints(3 hMost had acute complaints(3 h<)<) Overall mortality 1%Overall mortality 1%

Cocaine related complaintsCocaine related complaintsCocaine related complaintsCocaine related complaints

Brody,1990Brody,1990 Rich, 1991Rich, 1991

CVSCVS 40%40% 16%16%

NeuroNeuro 21%21% 25%25%

PsychiatricPsychiatric 27%27% 31%31%

TraumaTrauma -- 11%11%

GIGI 10%10% 8%8%

MSKMSK 9%9% 3%3%

Differential diagnosisDifferential diagnosisDifferential diagnosisDifferential diagnosis

Cardiomyopathy Myocarditis Pulmonary embolus or thrombus Pneumonia Endocarditis Aotic dissection Pneumothorax, pneumopericardium,

pneumomediastinum ACS

Cardiomyopathy Myocarditis Pulmonary embolus or thrombus Pneumonia Endocarditis Aotic dissection Pneumothorax, pneumopericardium,

pneumomediastinum ACS

Differential diagnosis(2)Differential diagnosis(2)Differential diagnosis(2)Differential diagnosis(2)

Most articles discuss the prevalence of Most articles discuss the prevalence of AMI/ACS.AMI/ACS.

Case reportsCase reports Most C/P will, in the end, have a benign Most C/P will, in the end, have a benign

diagnosis.diagnosis.

Most articles discuss the prevalence of Most articles discuss the prevalence of AMI/ACS.AMI/ACS.

Case reportsCase reports Most C/P will, in the end, have a benign Most C/P will, in the end, have a benign

diagnosis.diagnosis.

Prevalence studies-Cocaine MIPrevalence studies-Cocaine MIPrevalence studies-Cocaine MIPrevalence studies-Cocaine MI

0

5

10

15

20

25

30

35

40

Amin 1990 Zimmerman 1991 Hollander 94 Weber 2000 Feldman2000

%

ProblemsProblemsProblemsProblems

Subjected to reporting biasSubjected to reporting bias All studies done on All studies done on inpatients.inpatients. No studies use Troponin.No studies use Troponin. Small amount of long term follow-up.Small amount of long term follow-up. Population difficult to follow as outpatientPopulation difficult to follow as outpatient

Subjected to reporting biasSubjected to reporting bias All studies done on All studies done on inpatients.inpatients. No studies use Troponin.No studies use Troponin. Small amount of long term follow-up.Small amount of long term follow-up. Population difficult to follow as outpatientPopulation difficult to follow as outpatient

AMI vs ACSAMI vs ACSAMI vs ACSAMI vs ACS

All studies essentially look at incidence of MI.All studies essentially look at incidence of MI.

Questions:Questions: Acute event in a otherwise normal coronary?Acute event in a otherwise normal coronary? Prevalence of actual CAD ?Prevalence of actual CAD ? Prevalence of Acute Coronary Syndromes?Prevalence of Acute Coronary Syndromes? Reversible ischemia?Reversible ischemia?

All studies essentially look at incidence of MI.All studies essentially look at incidence of MI.

Questions:Questions: Acute event in a otherwise normal coronary?Acute event in a otherwise normal coronary? Prevalence of actual CAD ?Prevalence of actual CAD ? Prevalence of Acute Coronary Syndromes?Prevalence of Acute Coronary Syndromes? Reversible ischemia?Reversible ischemia?

People with chest painPeople with chest painUsers vs non-usersUsers vs non-users

People with chest painPeople with chest painUsers vs non-usersUsers vs non-users

American Survey 1995-1996American Survey 1995-1996 4639 chest pain visits4639 chest pain visits In the general population( ages 25-40)In the general population( ages 25-40) 5.6% of C/P in ED will be ACS5.6% of C/P in ED will be ACS 2.5% prevalence of AMI2.5% prevalence of AMI

Burt, Am. Jour. Of Emerg. Med, October 1999Burt, Am. Jour. Of Emerg. Med, October 1999

American Survey 1995-1996American Survey 1995-1996 4639 chest pain visits4639 chest pain visits In the general population( ages 25-40)In the general population( ages 25-40) 5.6% of C/P in ED will be ACS5.6% of C/P in ED will be ACS 2.5% prevalence of AMI2.5% prevalence of AMI

Burt, Am. Jour. Of Emerg. Med, October 1999Burt, Am. Jour. Of Emerg. Med, October 1999

EpidemiologyEpidemiologyEpidemiologyEpidemiology

High proportion is male ( 70-80%)High proportion is male ( 70-80%) Mostly African-AmericanMostly African-American Median age : 35 yoMedian age : 35 yo Cardiac risk similar vs controlCardiac risk similar vs control High concommitant use of cigarettesHigh concommitant use of cigarettes More likely to be admitted to ICU/CCUMore likely to be admitted to ICU/CCU Cost of 83 millions $$$$$$Cost of 83 millions $$$$$$

High proportion is male ( 70-80%)High proportion is male ( 70-80%) Mostly African-AmericanMostly African-American Median age : 35 yoMedian age : 35 yo Cardiac risk similar vs controlCardiac risk similar vs control High concommitant use of cigarettesHigh concommitant use of cigarettes More likely to be admitted to ICU/CCUMore likely to be admitted to ICU/CCU Cost of 83 millions $$$$$$Cost of 83 millions $$$$$$

Dangers of body-packingDangers of body-packingDangers of body-packingDangers of body-packing

Frequent vs non-frequent usersFrequent vs non-frequent usersFrequent vs non-frequent usersFrequent vs non-frequent users

Third Nationnal Health and Third Nationnal Health and Nutrition surveyNutrition survey

10 085 patients aged 18-45 10 085 patients aged 18-45 yoyo

731 infrequent users731 infrequent users 532 frequent users532 frequent users ( about 5% of population)( about 5% of population) 46 non fatal MI’s46 non fatal MI’s

HNADES III ’88-’94HNADES III ’88-’94

Third Nationnal Health and Third Nationnal Health and Nutrition surveyNutrition survey

10 085 patients aged 18-45 10 085 patients aged 18-45 yoyo

731 infrequent users731 infrequent users 532 frequent users532 frequent users ( about 5% of population)( about 5% of population) 46 non fatal MI’s46 non fatal MI’s

HNADES III ’88-’94HNADES III ’88-’94

Results:Results:1) OR 6.9 for 1) OR 6.9 for frequentfrequent users. users. CI95% 1.3 to 58CI95% 1.3 to 58

2) OR 0.1 2) OR 0.1 infrequentinfrequent users. users.CI95% 0.002 to 0.8 CI95% 0.002 to 0.8

*More smokers, HTN*More smokers, HTN

Results:Results:1) OR 6.9 for 1) OR 6.9 for frequentfrequent users. users. CI95% 1.3 to 58CI95% 1.3 to 58

2) OR 0.1 2) OR 0.1 infrequentinfrequent users. users.CI95% 0.002 to 0.8 CI95% 0.002 to 0.8

*More smokers, HTN*More smokers, HTN

Time to presentationTime to presentationTime to presentationTime to presentation

Mittleman and al., Circulation 99Mittleman and al., Circulation 99- 3946 MI patients3946 MI patients- 38 admitted to cocaine use38 admitted to cocaine use- 9 within 1h of MI9 within 1h of MI- 1within 2h of MI1within 2h of MI- 1 within 3h of MI1 within 3h of MI- RR 23.7 in the first hourRR 23.7 in the first hour

Mittleman and al., Circulation 99Mittleman and al., Circulation 99- 3946 MI patients3946 MI patients- 38 admitted to cocaine use38 admitted to cocaine use- 9 within 1h of MI9 within 1h of MI- 1within 2h of MI1within 2h of MI- 1 within 3h of MI1 within 3h of MI- RR 23.7 in the first hourRR 23.7 in the first hour

Prevalence of ACSPrevalence of ACSPrevalence of ACSPrevalence of ACS

Feldman, Annals of emergency med. 1999Feldman, Annals of emergency med. 1999

-241 patients over 2 years.-241 patients over 2 years.

- High risk (69) went directly to CCU.- High risk (69) went directly to CCU.

- Moderate and low risk had tehcnicium99 sestamibi - Moderate and low risk had tehcnicium99 sestamibi done in the following 90 min.done in the following 90 min.

- 6 MI’s (6/218= - 6 MI’s (6/218= 2.5%)2.5%) or or 8.7%8.7% of CCU patients of CCU patients

- Stress studies on 70 patients: 6 reversible ischemia - Stress studies on 70 patients: 6 reversible ischemia (6/67= 8.6%) at follow-up.(6/67= 8.6%) at follow-up.

- No recurrence at 30 days- No recurrence at 30 days

Feldman, Annals of emergency med. 1999Feldman, Annals of emergency med. 1999

-241 patients over 2 years.-241 patients over 2 years.

- High risk (69) went directly to CCU.- High risk (69) went directly to CCU.

- Moderate and low risk had tehcnicium99 sestamibi - Moderate and low risk had tehcnicium99 sestamibi done in the following 90 min.done in the following 90 min.

- 6 MI’s (6/218= - 6 MI’s (6/218= 2.5%)2.5%) or or 8.7%8.7% of CCU patients of CCU patients

- Stress studies on 70 patients: 6 reversible ischemia - Stress studies on 70 patients: 6 reversible ischemia (6/67= 8.6%) at follow-up.(6/67= 8.6%) at follow-up.

- No recurrence at 30 days- No recurrence at 30 days

CAD vs Non-CAD events ?CAD vs Non-CAD events ?CAD vs Non-CAD events ?CAD vs Non-CAD events ?

Review articles : 31 to 67% have CAD.Review articles : 31 to 67% have CAD.

Hollander , Meta-analysis, 1997Hollander , Meta-analysis, 1997

- 66 patients with cocaine-associated MI- 66 patients with cocaine-associated MI

- Angio-proven CAD in 41% of patients- Angio-proven CAD in 41% of patients

- Presence of other risk factors NOT associated - Presence of other risk factors NOT associated with greater incidence of CAD.with greater incidence of CAD.

Review articles : 31 to 67% have CAD.Review articles : 31 to 67% have CAD.

Hollander , Meta-analysis, 1997Hollander , Meta-analysis, 1997

- 66 patients with cocaine-associated MI- 66 patients with cocaine-associated MI

- Angio-proven CAD in 41% of patients- Angio-proven CAD in 41% of patients

- Presence of other risk factors NOT associated - Presence of other risk factors NOT associated with greater incidence of CAD.with greater incidence of CAD.

Complications/ short termComplications/ short termComplications/ short termComplications/ short term

Reported in the prospective studies: 5-10%Reported in the prospective studies: 5-10%

One study designed to look at complications:One study designed to look at complications:

- - Hoffman, Archives of internal med, 1995Hoffman, Archives of internal med, 1995

- Retrospective study of 130 patients with MI.- Retrospective study of 130 patients with MI.

- 36% had complications- 36% had complications

- 90% within 12 h of presentation- 90% within 12 h of presentation

- 48% on arrival to the ED- 48% on arrival to the ED

ComplicationsComplicationsComplicationsComplications

CHFCHF 7%7%

Nonsustained VTNonsustained VT 13%13%

Sustained VTSustained VT 4%4%

SVTSVT 4%4%

BradydysrhythmiasBradydysrhythmias 19%19%

MortalityMortalityMortalityMortality

Feldman 2000 : 0%Feldman 2000 : 0% Weber 2000: 0%Weber 2000: 0% Hoffman 1995: 0%Hoffman 1995: 0% Hollander 1994: 0%Hollander 1994: 0%

-No study reports death following arrival to the -No study reports death following arrival to the

hospital.hospital.

Feldman 2000 : 0%Feldman 2000 : 0% Weber 2000: 0%Weber 2000: 0% Hoffman 1995: 0%Hoffman 1995: 0% Hollander 1994: 0%Hollander 1994: 0%

-No study reports death following arrival to the -No study reports death following arrival to the

hospital.hospital.

In summaryIn summaryIn summaryIn summary

Up to 40% of cocaine-related complaintsUp to 40% of cocaine-related complaints Young populationYoung population SmokersSmokers Delayed presentationDelayed presentation Frequent users are more at riskFrequent users are more at risk Most complications occur within 12hMost complications occur within 12h Very low mortalityVery low mortality

Up to 40% of cocaine-related complaintsUp to 40% of cocaine-related complaints Young populationYoung population SmokersSmokers Delayed presentationDelayed presentation Frequent users are more at riskFrequent users are more at risk Most complications occur within 12hMost complications occur within 12h Very low mortalityVery low mortality

In summary(2)In summary(2)In summary(2)In summary(2)

6% prevalence of AMI in most studies.6% prevalence of AMI in most studies. Prevalence of ACS is not knownPrevalence of ACS is not known Maybe close to 9-10%Maybe close to 9-10% 30 to 67% of these patients have CAD30 to 67% of these patients have CAD

6% prevalence of AMI in most studies.6% prevalence of AMI in most studies. Prevalence of ACS is not knownPrevalence of ACS is not known Maybe close to 9-10%Maybe close to 9-10% 30 to 67% of these patients have CAD30 to 67% of these patients have CAD

PART IIIPART IIIPART IIIPART III

Animal testingAnimal testingAnimal testingAnimal testing

Part III Part III Cocaine- related ACSCocaine- related ACS

Part III Part III Cocaine- related ACSCocaine- related ACS

PathophysiologyPathophysiology

DiagnosisDiagnosis

TreatmentTreatment

ConclusionConclusion

PathophysiologyPathophysiology

DiagnosisDiagnosis

TreatmentTreatment

ConclusionConclusion

PathophysiologyPathophysiologyPathophysiologyPathophysiology

1) Increased workload on the heart1) Increased workload on the heart- Sympathomimetic stateSympathomimetic state- Increased afterloadIncreased afterload- Increased myocardial O2 needs.Increased myocardial O2 needs.

Impact:Impact: Rise in BP of 20/10mmHg Rise in BP of 20/10mmHg Rise in HR of 30 beats/minRise in HR of 30 beats/min

Equivalent to mild exercise at recretionnal doses.Equivalent to mild exercise at recretionnal doses.( 2 mg/kg).( 2 mg/kg).

1) Increased workload on the heart1) Increased workload on the heart- Sympathomimetic stateSympathomimetic state- Increased afterloadIncreased afterload- Increased myocardial O2 needs.Increased myocardial O2 needs.

Impact:Impact: Rise in BP of 20/10mmHg Rise in BP of 20/10mmHg Rise in HR of 30 beats/minRise in HR of 30 beats/min

Equivalent to mild exercise at recretionnal doses.Equivalent to mild exercise at recretionnal doses.( 2 mg/kg).( 2 mg/kg).

Pathophysiology(2)Pathophysiology(2)Pathophysiology(2)Pathophysiology(2)

Coronary vasoconstrictionCoronary vasoconstriction- Most human studies use doses 2mg/kg Most human studies use doses 2mg/kg 1-41-4

- Effect starts at 3-5 minEffect starts at 3-5 min

Decrease in diameter of 4% to 29%Decrease in diameter of 4% to 29%- Effect is worse on diseased arteries. Effect is worse on diseased arteries. 55

- Presence of temporal variationsPresence of temporal variations

1.1. 1)Lange and al., 1)Lange and al., N Engl J Med 1989;321:1557-62.2 )N Engl J Med 1989;321:1557-62.2 )Flores ED, Flores ED, Am Coll Cardiol 1990;16:74-9.Am Coll Cardiol 1990;16:74-9.3)3)Molnerto DJ, Molnerto DJ, N N

Engl J Med 1994;330:454-9. 4)Engl J Med 1994;330:454-9. 4)Majid MJ, Majid MJ, Clin Cardiol 1992;15:253-8Clin Cardiol 1992;15:253-8..5)5)Daniel WC, Daniel WC, Am J Cardiol 1996;78:288-91Am J Cardiol 1996;78:288-91

Coronary vasoconstrictionCoronary vasoconstriction- Most human studies use doses 2mg/kg Most human studies use doses 2mg/kg 1-41-4

- Effect starts at 3-5 minEffect starts at 3-5 min

Decrease in diameter of 4% to 29%Decrease in diameter of 4% to 29%- Effect is worse on diseased arteries. Effect is worse on diseased arteries. 55

- Presence of temporal variationsPresence of temporal variations

1.1. 1)Lange and al., 1)Lange and al., N Engl J Med 1989;321:1557-62.2 )N Engl J Med 1989;321:1557-62.2 )Flores ED, Flores ED, Am Coll Cardiol 1990;16:74-9.Am Coll Cardiol 1990;16:74-9.3)3)Molnerto DJ, Molnerto DJ, N N

Engl J Med 1994;330:454-9. 4)Engl J Med 1994;330:454-9. 4)Majid MJ, Majid MJ, Clin Cardiol 1992;15:253-8Clin Cardiol 1992;15:253-8..5)5)Daniel WC, Daniel WC, Am J Cardiol 1996;78:288-91Am J Cardiol 1996;78:288-91

Pathophysiology(3)Pathophysiology(3)Pathophysiology(3)Pathophysiology(3)

Thrombosis and platelet aggregation.Thrombosis and platelet aggregation.

- Cocaine associated to thrombus in coronary - Cocaine associated to thrombus in coronary arteries in some of the AMI cases.arteries in some of the AMI cases.

- Angiographic and pathologic evidence.- Angiographic and pathologic evidence.1-41-4

- Mecanism is believed to be expression of - Mecanism is believed to be expression of thrombogenic substances in-situthrombogenic substances in-situ

1)Simpson RW, 1)Simpson RW, Arch Pathol Lab Med 1986;110:479-84. Arch Pathol Lab Med 1986;110:479-84.

2)Cooke CT, 2)Cooke CT, Pathology 1988;20:242, 305-6 Pathology 1988;20:242, 305-6

3)Patel GQ, 3)Patel GQ, Circulation 1988;78(II Suppl):II436 Circulation 1988;78(II Suppl):II436

4)Steinberg RG,Arch Pathol Lab Med 1989;113:521-44)Steinberg RG,Arch Pathol Lab Med 1989;113:521-4

Thrombosis and platelet aggregation.Thrombosis and platelet aggregation.

- Cocaine associated to thrombus in coronary - Cocaine associated to thrombus in coronary arteries in some of the AMI cases.arteries in some of the AMI cases.

- Angiographic and pathologic evidence.- Angiographic and pathologic evidence.1-41-4

- Mecanism is believed to be expression of - Mecanism is believed to be expression of thrombogenic substances in-situthrombogenic substances in-situ

1)Simpson RW, 1)Simpson RW, Arch Pathol Lab Med 1986;110:479-84. Arch Pathol Lab Med 1986;110:479-84.

2)Cooke CT, 2)Cooke CT, Pathology 1988;20:242, 305-6 Pathology 1988;20:242, 305-6

3)Patel GQ, 3)Patel GQ, Circulation 1988;78(II Suppl):II436 Circulation 1988;78(II Suppl):II436

4)Steinberg RG,Arch Pathol Lab Med 1989;113:521-44)Steinberg RG,Arch Pathol Lab Med 1989;113:521-4

Pathophysiology (4)Pathophysiology (4)Pathophysiology (4)Pathophysiology (4)

Accelerated intracoronary atherosclerosisAccelerated intracoronary atherosclerosis

- - Wilson and al, Wilson and al, J Emerg Med 1998;16:631-4J Emerg Med 1998;16:631-4. .

- Review of previous series and 2 new cases.- Review of previous series and 2 new cases.#1 Significant LAD lesion over 10 months#1 Significant LAD lesion over 10 months

#2 Significant 3 vessel disease over 16 months#2 Significant 3 vessel disease over 16 months

- Rapid progression in chronic abusers.- Rapid progression in chronic abusers.

- Recurrence of ACS with continuous use.- Recurrence of ACS with continuous use.

Accelerated intracoronary atherosclerosisAccelerated intracoronary atherosclerosis

- - Wilson and al, Wilson and al, J Emerg Med 1998;16:631-4J Emerg Med 1998;16:631-4. .

- Review of previous series and 2 new cases.- Review of previous series and 2 new cases.#1 Significant LAD lesion over 10 months#1 Significant LAD lesion over 10 months

#2 Significant 3 vessel disease over 16 months#2 Significant 3 vessel disease over 16 months

- Rapid progression in chronic abusers.- Rapid progression in chronic abusers.

- Recurrence of ACS with continuous use.- Recurrence of ACS with continuous use.

PathophysiologyPathophysiology

EvaluationEvaluationEvaluationEvaluation

History and physical examination.History and physical examination.

EKGEKG

Cardiac enzymesCardiac enzymes

History and physical examination.History and physical examination.

EKGEKG

Cardiac enzymesCardiac enzymes

History and physical examHistory and physical examHistory and physical examHistory and physical exam

Unable to differentiate between the various causes Unable to differentiate between the various causes on the basis of the clinical evaluation.on the basis of the clinical evaluation.

- Localisation- Localisation

- Quality- Quality

- Associated symptoms- Associated symptoms

- Pleuritic component- Pleuritic component

* 28% of patients with MI had a pleuritic component. * 28% of patients with MI had a pleuritic component.

*Hofffman, Academic emergency med, 1994*Hofffman, Academic emergency med, 1994

Unable to differentiate between the various causes Unable to differentiate between the various causes on the basis of the clinical evaluation.on the basis of the clinical evaluation.

- Localisation- Localisation

- Quality- Quality

- Associated symptoms- Associated symptoms

- Pleuritic component- Pleuritic component

* 28% of patients with MI had a pleuritic component. * 28% of patients with MI had a pleuritic component.

*Hofffman, Academic emergency med, 1994*Hofffman, Academic emergency med, 1994

EKGEKGEKGEKG

Primary determinent to thrombolysis in AMI.Primary determinent to thrombolysis in AMI. Sensitivity: 54-89% ( 95% CI )Sensitivity: 54-89% ( 95% CI ) Specificity: 67-96% Specificity: 67-96%

Do these findings apply to cocaine-induced Do these findings apply to cocaine-induced chest pain?chest pain?

Primary determinent to thrombolysis in AMI.Primary determinent to thrombolysis in AMI. Sensitivity: 54-89% ( 95% CI )Sensitivity: 54-89% ( 95% CI ) Specificity: 67-96% Specificity: 67-96%

Do these findings apply to cocaine-induced Do these findings apply to cocaine-induced chest pain?chest pain?

EKG (2)EKG (2)EKG (2)EKG (2)

Gitter and al., Annals of int. Medicine, 1991Gitter and al., Annals of int. Medicine, 1991

- Serie of 101 patients with cocaine-C/P- Serie of 101 patients with cocaine-C/P

- 43% met TIMI criteria for reperfusion.- 43% met TIMI criteria for reperfusion.

- NO AMI found- NO AMI found

Tokarski, Ann. of emerg. Med, 1990Tokarski, Ann. of emerg. Med, 1990

- Serie of 42 patients- Serie of 42 patients

- All normal EKG’s- All normal EKG’s

- 19% of patients had CK-MB elevation- 19% of patients had CK-MB elevation

Gitter and al., Annals of int. Medicine, 1991Gitter and al., Annals of int. Medicine, 1991

- Serie of 101 patients with cocaine-C/P- Serie of 101 patients with cocaine-C/P

- 43% met TIMI criteria for reperfusion.- 43% met TIMI criteria for reperfusion.

- NO AMI found- NO AMI found

Tokarski, Ann. of emerg. Med, 1990Tokarski, Ann. of emerg. Med, 1990

- Serie of 42 patients- Serie of 42 patients

- All normal EKG’s- All normal EKG’s

- 19% of patients had CK-MB elevation- 19% of patients had CK-MB elevation

EKG (3)EKG (3)EKG (3)EKG (3)

Pitfalls : Pitfalls :

- High prevalence of repolarisation abnormalities - High prevalence of repolarisation abnormalities in young population. (BER).in young population. (BER).

- Presence of repolarisation abnormalities in - Presence of repolarisation abnormalities in cocaine users without C/P.cocaine users without C/P.

- Higher incidence of left ventricular - Higher incidence of left ventricular hypertrophy in cocaine users.hypertrophy in cocaine users.

Pitfalls : Pitfalls :

- High prevalence of repolarisation abnormalities - High prevalence of repolarisation abnormalities in young population. (BER).in young population. (BER).

- Presence of repolarisation abnormalities in - Presence of repolarisation abnormalities in cocaine users without C/P.cocaine users without C/P.

- Higher incidence of left ventricular - Higher incidence of left ventricular hypertrophy in cocaine users.hypertrophy in cocaine users.

EKG(4)EKG(4)EKG(4)EKG(4)

Are abnormal EKG’s in cocaine-induced C/P due Are abnormal EKG’s in cocaine-induced C/P due to normal variants?to normal variants?

Study of 112 patients ( 56 per group)Study of 112 patients ( 56 per group) Young (mean 28yo), Non-caucasianYoung (mean 28yo), Non-caucasian Few other risk factors for CADFew other risk factors for CAD 2 independent physicians2 independent physicians Kappa 0.70Kappa 0.70

Hollander, Acad. Emerg med, 1994Hollander, Acad. Emerg med, 1994

Are abnormal EKG’s in cocaine-induced C/P due Are abnormal EKG’s in cocaine-induced C/P due to normal variants?to normal variants?

Study of 112 patients ( 56 per group)Study of 112 patients ( 56 per group) Young (mean 28yo), Non-caucasianYoung (mean 28yo), Non-caucasian Few other risk factors for CADFew other risk factors for CAD 2 independent physicians2 independent physicians Kappa 0.70Kappa 0.70

Hollander, Acad. Emerg med, 1994Hollander, Acad. Emerg med, 1994

EKG(5)EKG(5)EKG(5)EKG(5)

9-16% of controls had Normal EKG (4-13%)9-16% of controls had Normal EKG (4-13%) 5-18% of controls had Ischemic ( 13-25%)5-18% of controls had Ischemic ( 13-25%) 5% of controls met TIMI criterias (13%)5% of controls met TIMI criterias (13%)

Conclusion: Conclusion:

- High prevalence in « normal » population- High prevalence in « normal » population

- Further increase in cocaine users- Further increase in cocaine users

« ischemic » ( 22 vs 13%)« ischemic » ( 22 vs 13%)

9-16% of controls had Normal EKG (4-13%)9-16% of controls had Normal EKG (4-13%) 5-18% of controls had Ischemic ( 13-25%)5-18% of controls had Ischemic ( 13-25%) 5% of controls met TIMI criterias (13%)5% of controls met TIMI criterias (13%)

Conclusion: Conclusion:

- High prevalence in « normal » population- High prevalence in « normal » population

- Further increase in cocaine users- Further increase in cocaine users

« ischemic » ( 22 vs 13%)« ischemic » ( 22 vs 13%)

EKGEKGSensitivity and specificitySensitivity and specificity

EKGEKGSensitivity and specificitySensitivity and specificity

Hollander, Hoffman, « Prospective multicenter Hollander, Hoffman, « Prospective multicenter evaluation of Cocaine-associated chest pain. », evaluation of Cocaine-associated chest pain. »,

Acad. Emerg. Med., 1994Acad. Emerg. Med., 1994

Sensivity: 35.7%Sensivity: 35.7% Specificity: 89.9%Specificity: 89.9% PPV: 17.9%PPV: 17.9% NPV: 95.8%NPV: 95.8%

Hollander, Hoffman, « Prospective multicenter Hollander, Hoffman, « Prospective multicenter evaluation of Cocaine-associated chest pain. », evaluation of Cocaine-associated chest pain. »,

Acad. Emerg. Med., 1994Acad. Emerg. Med., 1994

Sensivity: 35.7%Sensivity: 35.7% Specificity: 89.9%Specificity: 89.9% PPV: 17.9%PPV: 17.9% NPV: 95.8%NPV: 95.8%

Cardiac enzymesCardiac enzymesCardiac enzymesCardiac enzymes

All studies reviewed are using CK-MB.All studies reviewed are using CK-MB.

Is the specificity of cardiac markers changed in Is the specificity of cardiac markers changed in cocaine users ?cocaine users ?

Answer: Answer:

1) Mildly for CK-MB ( 75% users vs 88% in non-1) Mildly for CK-MB ( 75% users vs 88% in non-users)users)

2) Troponin I : not affected (94% in both group)2) Troponin I : not affected (94% in both group)

Hollander, Am. Jour. of Cardiology, 1998Hollander, Am. Jour. of Cardiology, 1998

All studies reviewed are using CK-MB.All studies reviewed are using CK-MB.

Is the specificity of cardiac markers changed in Is the specificity of cardiac markers changed in cocaine users ?cocaine users ?

Answer: Answer:

1) Mildly for CK-MB ( 75% users vs 88% in non-1) Mildly for CK-MB ( 75% users vs 88% in non-users)users)

2) Troponin I : not affected (94% in both group)2) Troponin I : not affected (94% in both group)

Hollander, Am. Jour. of Cardiology, 1998Hollander, Am. Jour. of Cardiology, 1998

TreatmentTreatmentTreatmentTreatment

ASAASA NitratesNitrates ββ- blockers- blockers αα- blockers- blockers Calcium channel blockersCalcium channel blockers BenzodiazepinesBenzodiazepines AnticoagulantsAnticoagulants Reperfusion strategiesReperfusion strategies

ASAASA NitratesNitrates ββ- blockers- blockers αα- blockers- blockers Calcium channel blockersCalcium channel blockers BenzodiazepinesBenzodiazepines AnticoagulantsAnticoagulants Reperfusion strategiesReperfusion strategies

ASAASAASAASA

First line agent in ACSFirst line agent in ACS NO formal studies in the context of cocaine- NO formal studies in the context of cocaine-

related ACSrelated ACS Makes sense to give for its antiplatelet activity.Makes sense to give for its antiplatelet activity. Caution against its use if SAH is suspected.Caution against its use if SAH is suspected.

Hollander, NEJM, 1995.Hollander, NEJM, 1995.

Lange and Hillis, NEJM, 2001Lange and Hillis, NEJM, 2001

Hoffman, Emerg. Med clinics, 2001Hoffman, Emerg. Med clinics, 2001

First line agent in ACSFirst line agent in ACS NO formal studies in the context of cocaine- NO formal studies in the context of cocaine-

related ACSrelated ACS Makes sense to give for its antiplatelet activity.Makes sense to give for its antiplatelet activity. Caution against its use if SAH is suspected.Caution against its use if SAH is suspected.

Hollander, NEJM, 1995.Hollander, NEJM, 1995.

Lange and Hillis, NEJM, 2001Lange and Hillis, NEJM, 2001

Hoffman, Emerg. Med clinics, 2001Hoffman, Emerg. Med clinics, 2001

BenzodiazepinesBenzodiazepinesBenzodiazepinesBenzodiazepines

Works by stimulation of GABA receptors.Works by stimulation of GABA receptors. Agent of choice to control agitation and other Agent of choice to control agitation and other

sympatomimetic symptoms.sympatomimetic symptoms. Protects against seizures.Protects against seizures. Anxiolytic effectAnxiolytic effect Mechanism of action in cocaine-induced Mechanism of action in cocaine-induced

C/P???C/P???

Works by stimulation of GABA receptors.Works by stimulation of GABA receptors. Agent of choice to control agitation and other Agent of choice to control agitation and other

sympatomimetic symptoms.sympatomimetic symptoms. Protects against seizures.Protects against seizures. Anxiolytic effectAnxiolytic effect Mechanism of action in cocaine-induced Mechanism of action in cocaine-induced

C/P???C/P???

BenzodiazepinesBenzodiazepinesBenzodiazepinesBenzodiazepines

Decreases the adrenergic stateDecreases the adrenergic state Decreases O2 requirements and workload.Decreases O2 requirements and workload. No demonstrated effect on coronaries.No demonstrated effect on coronaries.

Are benzos better then nitro in cocaine-induced Are benzos better then nitro in cocaine-induced chest pain ?chest pain ?

Baumann, Baumann, Acad. Emerg Med, 2000Acad. Emerg Med, 2000Baumann, Baumann, Acad. Emerg Med, 2000Acad. Emerg Med, 2000

Randomised double-blind placebo controlled Randomised double-blind placebo controlled study.study.

40 patients, Diazepam, Nitro, or both.40 patients, Diazepam, Nitro, or both. OutcomesOutcomes: chest pain score, vital signs and : chest pain score, vital signs and

hemodynamic monitoringhemodynamic monitoring Results:Results:

- No difference between the 2 drugs- No difference between the 2 drugs

- No beneficial effect of combination of both- No beneficial effect of combination of both

Randomised double-blind placebo controlled Randomised double-blind placebo controlled study.study.

40 patients, Diazepam, Nitro, or both.40 patients, Diazepam, Nitro, or both. OutcomesOutcomes: chest pain score, vital signs and : chest pain score, vital signs and

hemodynamic monitoringhemodynamic monitoring Results:Results:

- No difference between the 2 drugs- No difference between the 2 drugs

- No beneficial effect of combination of both- No beneficial effect of combination of both

NitroglycerinNitroglycerinNitroglycerinNitroglycerin

Standard of care in ACSStandard of care in ACS Coronary vasodilator in ACS.Coronary vasodilator in ACS. Experimental evidence of reversal of coronary Experimental evidence of reversal of coronary

vasospam caused by cocaine.vasospam caused by cocaine. Good to lower BP.Good to lower BP. No advantage over benzos ( Baumann 2000)No advantage over benzos ( Baumann 2000) Place in therapyPlace in therapy

Standard of care in ACSStandard of care in ACS Coronary vasodilator in ACS.Coronary vasodilator in ACS. Experimental evidence of reversal of coronary Experimental evidence of reversal of coronary

vasospam caused by cocaine.vasospam caused by cocaine. Good to lower BP.Good to lower BP. No advantage over benzos ( Baumann 2000)No advantage over benzos ( Baumann 2000) Place in therapyPlace in therapy

ββ-Blockers-Blockersββ-Blockers-Blockers

UGE controversy in the literatureUGE controversy in the literature 2000 AHA TOX-ACLS recommendations2000 AHA TOX-ACLS recommendations Good quality evidence to exclude non-Good quality evidence to exclude non-

selective selective ββ-blockers.-blockers. Selective Selective ββ-blockers and mixed -blockers and mixed αα//ββ (labetalol) (labetalol)

are not recommended but not C-Iare not recommended but not C-I

UGE controversy in the literatureUGE controversy in the literature 2000 AHA TOX-ACLS recommendations2000 AHA TOX-ACLS recommendations Good quality evidence to exclude non-Good quality evidence to exclude non-

selective selective ββ-blockers.-blockers. Selective Selective ββ-blockers and mixed -blockers and mixed αα//ββ (labetalol) (labetalol)

are not recommended but not C-Iare not recommended but not C-I

αα-Blockers-Blockersαα-Blockers-Blockers

Prototype drug is phentolamine.Prototype drug is phentolamine. AHA 2000 : Class IIbAHA 2000 : Class IIb Reverses vasoconstriction Reverses vasoconstriction Based on animal and human studies.Based on animal and human studies. No RDM clinical trial or safety studies.No RDM clinical trial or safety studies. Use of a low dose is recommendedUse of a low dose is recommended..

Hollander JE, Carter WA, Hoffman RS. Use of phentolamine for Hollander JE, Carter WA, Hoffman RS. Use of phentolamine for cocainecocaine-induced -induced

myocardial ischemia. N Engl J Med 1992;327:361-361myocardial ischemia. N Engl J Med 1992;327:361-361

Prototype drug is phentolamine.Prototype drug is phentolamine. AHA 2000 : Class IIbAHA 2000 : Class IIb Reverses vasoconstriction Reverses vasoconstriction Based on animal and human studies.Based on animal and human studies. No RDM clinical trial or safety studies.No RDM clinical trial or safety studies. Use of a low dose is recommendedUse of a low dose is recommended..

Hollander JE, Carter WA, Hoffman RS. Use of phentolamine for Hollander JE, Carter WA, Hoffman RS. Use of phentolamine for cocainecocaine-induced -induced

myocardial ischemia. N Engl J Med 1992;327:361-361myocardial ischemia. N Engl J Med 1992;327:361-361

Calcium channel blockersCalcium channel blockersCalcium channel blockersCalcium channel blockers

Coronary artery vasodilator.Coronary artery vasodilator. Decreases afterload.Decreases afterload. Not reviewed in Tox-ACLS.Not reviewed in Tox-ACLS. One human study (10 patients).One human study (10 patients).11

Conclusion: Cannot recommend routinelyConclusion: Cannot recommend routinely

1.Negus BH, Willard JE, Hillis LD, et al. Alleviation of 1.Negus BH, Willard JE, Hillis LD, et al. Alleviation of cocainecocaine-induced coronary -induced coronary vasoconstriction with intravenous verapamil. Am J Cardiol 1994;73:510-513vasoconstriction with intravenous verapamil. Am J Cardiol 1994;73:510-513

Coronary artery vasodilator.Coronary artery vasodilator. Decreases afterload.Decreases afterload. Not reviewed in Tox-ACLS.Not reviewed in Tox-ACLS. One human study (10 patients).One human study (10 patients).11

Conclusion: Cannot recommend routinelyConclusion: Cannot recommend routinely

1.Negus BH, Willard JE, Hillis LD, et al. Alleviation of 1.Negus BH, Willard JE, Hillis LD, et al. Alleviation of cocainecocaine-induced coronary -induced coronary vasoconstriction with intravenous verapamil. Am J Cardiol 1994;73:510-513vasoconstriction with intravenous verapamil. Am J Cardiol 1994;73:510-513

AntiarythmicsAntiarythmicsAntiarythmicsAntiarythmics

Cocaine acts as Cocaine acts as Class IaClass Ia Tox-ACLS : HTox-ACLS : H22COCO33 is first line is first line

Safety of Lidocaine?Safety of Lidocaine?

-RD Shih, -RD Shih, Annals of Emergency Medicine Annals of Emergency Medicine Volume 26 • Number Volume 26 • Number 6 • December 19956 • December 1995

- - Risk is high based on animal studies.Risk is high based on animal studies.

- - Time from lastTime from last cocaine consumption seems cocaine consumption seems important.important.

Cocaine acts as Cocaine acts as Class IaClass Ia Tox-ACLS : HTox-ACLS : H22COCO33 is first line is first line

Safety of Lidocaine?Safety of Lidocaine?

-RD Shih, -RD Shih, Annals of Emergency Medicine Annals of Emergency Medicine Volume 26 • Number Volume 26 • Number 6 • December 19956 • December 1995

- - Risk is high based on animal studies.Risk is high based on animal studies.

- - Time from lastTime from last cocaine consumption seems cocaine consumption seems important.important.

ThrombolysisThrombolysisThrombolysisThrombolysis

Pros: Pros:

- Proven thrombotic component - Proven thrombotic component

- Improved mortality/morbodity in traditionnal - Improved mortality/morbodity in traditionnal AMIAMI

- Available in most centers- Available in most centers

Pros: Pros:

- Proven thrombotic component - Proven thrombotic component

- Improved mortality/morbodity in traditionnal - Improved mortality/morbodity in traditionnal AMIAMI

- Available in most centers- Available in most centers

ThrombolysisThrombolysisThrombolysisThrombolysis

ConsCons

- Low mortality in this patient population.- Low mortality in this patient population.

- No proven benefit in cocaine-AMI.- No proven benefit in cocaine-AMI.

- Risk of hemorrhage.- Risk of hemorrhage.

- Difficult EKG interpretation in this - Difficult EKG interpretation in this population.population.

ConsCons

- Low mortality in this patient population.- Low mortality in this patient population.

- No proven benefit in cocaine-AMI.- No proven benefit in cocaine-AMI.

- Risk of hemorrhage.- Risk of hemorrhage.

- Difficult EKG interpretation in this - Difficult EKG interpretation in this population.population.

Thrombolysis- complicationsThrombolysis- complicationsThrombolysis- complicationsThrombolysis- complications

« traditionnal AMI » risk of intracranial bleed « traditionnal AMI » risk of intracranial bleed is 0.95% in a serie of 71 000 AMI patients.is 0.95% in a serie of 71 000 AMI patients.

3 case reports in the literature.3 case reports in the literature. Reported thrombolysis complication rate for Reported thrombolysis complication rate for

cocaine-related AMI is 0 to 12% (95%CI).cocaine-related AMI is 0 to 12% (95%CI).

« traditionnal AMI » risk of intracranial bleed « traditionnal AMI » risk of intracranial bleed is 0.95% in a serie of 71 000 AMI patients.is 0.95% in a serie of 71 000 AMI patients.

3 case reports in the literature.3 case reports in the literature. Reported thrombolysis complication rate for Reported thrombolysis complication rate for

cocaine-related AMI is 0 to 12% (95%CI).cocaine-related AMI is 0 to 12% (95%CI).

Thrombolysis-SafetyThrombolysis-SafetyThrombolysis-SafetyThrombolysis-Safety

Hollander/ Hoffman, Chest, 1995Hollander/ Hoffman, Chest, 1995 Serie of 67 patients with Cocaine-MISerie of 67 patients with Cocaine-MI 25 received thrombolysis25 received thrombolysis 14/21 had evidence of reperfusion14/21 had evidence of reperfusion No complicationsNo complications

Hollander/ Hoffman, Chest, 1995Hollander/ Hoffman, Chest, 1995 Serie of 67 patients with Cocaine-MISerie of 67 patients with Cocaine-MI 25 received thrombolysis25 received thrombolysis 14/21 had evidence of reperfusion14/21 had evidence of reperfusion No complicationsNo complications

Summary-TreatmentSummary-TreatmentSummary-TreatmentSummary-Treatment

Agressive first line treatment is recommendedAgressive first line treatment is recommended..

If no response : trial of second line medications and If no response : trial of second line medications and arrange for possible Cath-Lab.arrange for possible Cath-Lab.

If doubt on the diagnosis try to get rapid If doubt on the diagnosis try to get rapid confirmation of diagnosis (Echo, Technicium99)confirmation of diagnosis (Echo, Technicium99)

Consider thrombolysisConsider thrombolysis

Agressive first line treatment is recommendedAgressive first line treatment is recommended..

If no response : trial of second line medications and If no response : trial of second line medications and arrange for possible Cath-Lab.arrange for possible Cath-Lab.

If doubt on the diagnosis try to get rapid If doubt on the diagnosis try to get rapid confirmation of diagnosis (Echo, Technicium99)confirmation of diagnosis (Echo, Technicium99)

Consider thrombolysisConsider thrombolysis

ConclusionConclusionConclusionConclusion

Chest pain is the most common chief Chest pain is the most common chief complaint of cocaine users.complaint of cocaine users.

High prevalence of CAD in this population. High prevalence of CAD in this population. Up to 10% will have an acute coronary Up to 10% will have an acute coronary

syndromesyndrome History and EKG may be misleading.History and EKG may be misleading.

Chest pain is the most common chief Chest pain is the most common chief complaint of cocaine users.complaint of cocaine users.

High prevalence of CAD in this population. High prevalence of CAD in this population. Up to 10% will have an acute coronary Up to 10% will have an acute coronary

syndromesyndrome History and EKG may be misleading.History and EKG may be misleading.

Conclusion(2)Conclusion(2)Conclusion(2)Conclusion(2)

Observe and obtain serial enzymes.Observe and obtain serial enzymes. Treat keeping in mind the pathophysiology of Treat keeping in mind the pathophysiology of

cocaine related AMI.cocaine related AMI. Disposition: Disposition:

- 12h observation period- 12h observation period

- Close follow-up for stress-testing- Close follow-up for stress-testing Treat the addiction.Treat the addiction.

Observe and obtain serial enzymes.Observe and obtain serial enzymes. Treat keeping in mind the pathophysiology of Treat keeping in mind the pathophysiology of

cocaine related AMI.cocaine related AMI. Disposition: Disposition:

- 12h observation period- 12h observation period

- Close follow-up for stress-testing- Close follow-up for stress-testing Treat the addiction.Treat the addiction.

Thank YOUThank YOUThank YOUThank YOU

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