Cocaine-Using Patients With a Normal or Nondiagnostic Electrocardiogram: Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging and Outcome

Division of Cardiovascular Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA.
Clinical Cardiology (Impact Factor: 2.59). 06/2012; 35(6):354-8. DOI: 10.1002/clc.21977
Source: PubMed


Few trials have examined the outcomes of patients who use cocaine with chest pain and who have a normal or nondiagnostic electrocardiogram (ECG) and the use of single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI).
We sought to compare the characteristics and overall outcomes in cocaine users vs non-cocaine users presenting to the emergency department with a normal/nondiagnostic ECG and to assess the value of rest MPI in both of these populations.
Patients with symptoms compatible with myocardial ischemia, suspected acute coronary syndrome (ACS), and a normal/nondiagnostic ECG were enrolled in the Emergency Room Assessment of Sestamibi for Evaluation of Chest Pain (ERASE Chest Pain) trial, a randomized controlled trial designed to evaluate the impact of rest MPI on triage decisions. Cocaine users (n = 294) were compared to non-cocaine users (n = 2180). Cocaine users were younger than non-cocaine users, and 72% were male.
Among the cocaine users, 2.4% had a myocardial infarction, 1.4% required percutaneous coronary intervention, and none of the patients underwent coronary artery bypass graft surgery. Among cocaine users with a final diagnosis of not ACS, randomization of patients to rest SPECT MPI resulted in an appropriate reduction in hospital admissions in both the cocaine users (P = 0.011) and the non-cocaine users (P < 0.001), suggesting improved triage when MPI was used.
Cocaine users with a normal/nondiagnostic ECG are at low risk of cardiac events. Even though cocaine users are at low risk of cardiac events, SPECT MPI remains effective in the risk stratification and improves triage management decisions resulting in lower admission rates and more discharges to home.

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    • "Ruling out cardiac events more rapidly should involve the use of additional imaging, provocative testing, or more frequent serum biomarkers for detecting myocardial damage. Hendel and colleagues reported on the use of single-photon emission computed tomography myocardial perfusion imaging (MPI) in 151 patients with cocaine chest pain and found that it effectively ruled out cardiac events and lowered admission rates.15 Paraschin and colleagues applied cardiac CT angiography (CTA) in 24 cocaine users presenting with chest pain. "
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    • " conditions such as vasospasm , Prinzmetal ' s angina , syndrome X , and micro - vasccular disease in which the underlying pathology is not readily detectable ; ( 3 ) other medical conditions that result in symptom profiles similar to cardiac chest pain ; and ( 4 ) substance - use - related chest pain , particularly those associated with cocaine ( Hendel et al . , 2012 ; Kloner , Hale , Alker , & Rezkalla , 1992 ; Kuhn , Gillis , Virmani , Visner , & Schaer , 1992 ) ."
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