cocaine and heart disease

8/3/2019 Cocaine and Heart Disease

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Cardiology Conference

Rodney Samaan, MD, MPH

11/18/09


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History

1884 Sigmund Freud publishes On Coca ; he recommends theuse of cocaine in the treatment of various conditions

1886 Introduction of Coca-Cola: contains cocaine syrup

1895 First cases of associated deaths reported in the Lancet

1912 5000 cocaine related fatalities per year

1914 Harrisons Narcotics Act:"An Act To provide for the registration of, withcollectors of internal revenue, and to impose a special tax on all persons who produce,import, manufacture, compound, deal in, dispense, sell, distribute, or give away opiumor coca leaves, their salts, derivatives, or preparations, and for other purposes."

1970s -80s Days of Glory

Mid-80s Freebase cocaine


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Onset and duration of actionOnset and duration of action

ROUTE ONSET PEAK (min)DURATION(min)

Inhalationor Iv

Seconds 3-5 15-30

Insufflation

1-3 min 20-30 60-90


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Pathophysiology

Cocaine users have elevated levels ofC-reactive protein,von Willebrand factor,and fibrinogen that may alsocontribute to thrombosis

Cocaine, therefore, causes myocardial ischemia or MI ina multifactorial fashion that includes:

(1) increasing myocardial oxygen demand by increasingheart rate, blood pressure, and contractility;

(2) decreasing oxygen supply via vasoconstriction;

(3) inducing a prothrombotic state by stimulating

platelet activation and altering the balance betweenprocoagulant and anticoagulant factors; and

(4) accelerating atherosclerosis.


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IncreasedPrevalence of Coronary Artery Aneurysms Among

Cocaine Users

Coronaryarteryaneurysms (CAAs),definedasaneurysmaldilatations >1.5 times

the normalcoronarysegment, can be divided into discrete aneurysms(localized dilatation, either saccular or fusiform) or ectasia (diffusedilatation involving 50% of the artery).

The incidence of CAA ranges from 0.2% to 5.3% with the largestantemortem series found in the Coronary Artery Surgery Study (CASS)

registry (4.9% of 20 087 patients referred for coronary angiography).

CAAs are most commonly associated with atherosclerosis but also arereported with Kawasakis disease, arteritis (polyarteritis nodosa,syphilis, systemic lupus erythematosis, Takayasus arteritis), mycoses,trauma, connective tissue disorders (Marfans and Ehlers-Danlossyndromes), metastatic tumors, polycystic kidney disease

After observing the presence of severe coronary ectasia in severalyoung cocaine users, the authors hypothesized that cocaine useincreases the prevalence of CAA

The study population included 112 consecutive patients over a 10-yearperiod with a history of cocaine use and coronary angiography. Of the

patients with reliable documentation regarding frequency and methodof cocaine abuse, 66% reportedatleast weeklyuse.


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Cont

Sixty-nine percent reported smoking or intranasal use; 7%,intravenous use; and 24%, multiple routes of administration. Toprovide a control group, a cohort of 79 patients of similar age andrisk factors was selected from a preexisting angiographic databaseof 300 consecutive patients within the time period of the studygroup.

To provide a similar age distribution, all patients


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Hollanderandal. Annalsof emergency

medicine 1994 Prevalence of cocaine use in patients older then 18 y

presenting with CP

359 patients

Anonymous urine collection on everybody

Found 20 % prevalence inurbanarea

Prevalence of7% atthe ruralsites

28% of positives denied use


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In the COCaine Associated CHestPAin (COCHPA) study,cocaine-associated MI occurred in 6% of patients who

presented to the ED with chest pain after cocaine use

Overall incidence of cocaine-associated MI variesbetween studies from 0.7% to 6% of those presentingwith chest pain after cocaine ingestion (some of the

variance may relate to differences in MI diagnosticcriteria), cocaine appears to be an importantcontributor to MI among the young

Hollander JE, Hoffman RS, Gennis P, Fairweather P, DiSano MJ, Schumb DA, Feldman JA, Fish SS,Dyer S, Wax P, Whelan C, Schwartzwald E. Prospective multicenter evaluation of cocaine-associated chestpain. Cocaine Associated Chest Pain (COCHPA) Study Group. Acad Emerg Med. 1994; 1: 330339.


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Rich, Annalsof EM, June 1991

Cocaine related Symptomsinpatientspresentingtothe ED

146 patients

Retrospective chart review

Overall prevalence 16% for CP (23 patients)

Total of 3 patients admitted

Stronger association with nasal route (11/23)


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Brody, Am. Journalofmedicine, 1990

Cocaine-relatedmedicalproblems

233 patients

Retrospective chart review

40% prevalence of CP

Most had acute complaints (3 h


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Prevalence studies-Cocaine MIPrevalence studies-Cocaine MI


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m ng e ween oca ne se an

MyocardialInfarctionHollander JE, Hoffman RS. Cocaine-induced myocardial infarction: an analysis and review of theliterature. J Emerg Med. 1992; 10: 169177

Cocaine-associated MI appears to occur most oftensoonaftercocaine ingestion. In one study, two thirds ofMI events occurred within 3 hoursofcocaine ingestion

Survey of 3946 patients with recent MI, 38 patientsadmitted to cocaine use in the preceding year, and 9patients reported ingestion in the 60 minutespreceding the onset of MI symptoms

This survey reported a striking 24-foldhigher risk of MIinthe firsthouraftercocaine use, with a rapid decrease inrisk after this time


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F

requentvsnon-frequentusers Third National Health and

Nutrition survey

10 085 patients aged 18-

45 yo

731 infrequent users

532 frequent users

( about 5% ofpopulation)

46non fatal MIs

NHANES III 88-94

Results:1) OR 6.9 for *frequent

users.CI95% 1.3 to 58

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

*More smokers, HTN


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EKG

An abnormal ECG has been reported in 5

6% to 84% ofpatients withcocaine-associated chest pain; however, many of these patients are

young and commonly have the normal variant ofearly repolarization,which may be interpreted by physicians as an abnormal ECG finding

Gitter and colleagues reported an early repolarizationpatternin 32% ofpatients with cocaine-associated chest pain, a left ventricularhypertrophy pattern in 16%, and a normal ECG inonly 32% ofpatients.

Overall, 42% ofpatientsintheircohortof 101 patientsmanifestedelectrocardiographic ST-segment elevation, although all of themeventually had MI excluded by cardiac marker testing

In the COCHPA (Cocaine Associated Chest Pain) study, the sensitivityof an ECG revealing ischemia or MI to predict a true MI wasonly 36%

Gitter MJ, Goldsmith SR, Dunbar DN, Sharkey SW. Cocaine and chest pain: clinical features and outcome of patients hospitalized to rule

out myocardial infarction. AnnIntern Med. 1991;115:277282.


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CardiacBiomarkersHollander, Am. J. of Cardiology, 1998

All studies reviewed using CK-MB

Is the specificity of cardiac markers changed incocaine users ?

Answer:

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

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

Cocaine ingestion may cause rhabdomyolysis with consequentelevation in myoglobin and total creatine kinase levels, which mayconfound the diagnosis of cocaine-associated MI


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T

reatment ASA

Benzodiazepines

Nitrates - blockers

- blockers

Calcium channel blockers

Anticoagulants

Reperfusion strategies


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B

enzodiaz

epin

es

Works by stimulation ofGABA receptors

Agent of choice to control agitation and other sympatomimeticsymptoms

Protects against seizures

Anxiolytic effect

Mechanism of action in cocaine-induced CP; more related to itsneuro effects that subsequently affect the CVS (decreaseadrenegic response)

Decreases O2 requirementsand workload

No demonstrated effect on coronaries


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Are benzos better then nitroin cocaine-induced chest

pain?


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Baumann, Acad. Emerg Med, 2000

Randomised double-blind placebo controlled study

40 patients, Diazepam, Nitro, or both

Outcomes: chest pain score, vital signs andhemodynamic monitoring

Results:

- No difference between the 2 drugs - No beneficial effect of combination of both


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Nitroglycerin

Standard of care in ACS

Coronary vasodilator in ACS

Experimental evidence of reversal ofcoronary vasospam caused by cocaine

Good to lower BP

No advantage over benzos ( Baumann2000)


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Calcium Channel blockers

This observation raises a question as to the role, ifany, of calcium antagonists in cocaine toxicity

Studies supporting the use of calcium channelblockers have been performed only in animal models

Consistent with a local anesthetic mechanism of itstoxic effects, calciumchannel blockershave not beenshownto reduce cocaine toxicityinhumans

Furthermore, they increase the lethality of cocaine.This additive lethality may result from the negativeinotropic effects


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Calciumchannel blockers

Coronary artery vasodilator

Decreases afterload

One human study (10 patients)

Conclusion: Cannot recommend routinely

Negus BH, Willard JE, Hillis LD, et al. Alleviation ofcocaine-inducedcoronar vasoconstriction with intravenous vera amil. Am J Cardiol


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BetaBlockers

Controversy in the literature

2000 AHA TOX-ACLS recommendations:

Good quality evidence to exclude non-selective -blockers

Selective -blockers and mixed / (labetalol) are not recommended but notcontraindicated

Propranolol exacerbates the depressionofcoronary blood flow induced by cocaine becauseof unopposed alpha stimulation after beta-blockade

Esmolol is a selective beta1-adrenergic blocker with rapid onset and short duration ofaction (elimination half-life, 9 min)

Coadministration of esmolol and sodium nitroprusside should be reserved for severehypertension that is unresponsive to other treatment and/or complicated by aorticdissection


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BetaBlockers

Third-line agent for drug-induced hypertensive emergencies

However,labetalol,acombinedalpha- and beta-blockingagent,hasanalpha-to-beta blockade ratioof 1:7

Therefore, it may not provide enough protection forcocaine-toxic patients from (relatively) unopposed alphastimulation

Its risk of exacerbating myocardial ischemia parallels the

risk of other beta-blockers


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-Blockers

phentolamine

AHA 2000: ClassIIb

Reverses vasoconstriction

Based on animal and human studies

No randomized clinical trials or safety studies

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


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Cocaine-associated VF

Cocaine activation of myocardial alpha-adrenergicreceptors, specifically alpha1A-adrenergic receptors, maysubstantially contribute to VF during myocardialischemia

Activation of these receptors elevates cytosoliccalciumlevelsandprovokesdelayedafter-depolarizations

Therefore, calciumoverloadmay be the finalcommonpathwaylinking enhancedadrenergicactivitytococaine-induced VF


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Thrombolysis

Pros:

- Improved mortality/morbidity in

traditionnal AMI

- Available in most centers


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Thrombolysis

Cons

- No proven benefit in cocaine-AMI

- Risk of hemorrhage

- Difficult EKG interpretation in thispopulation


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Thrombolysis- complications

Traditionnal AMI risk of intracranialbleed is 0.95% in a series of 71 000

AMI patients

Reported thrombolysis complicationrate for cocaine-related AMI is 0to

12% (95%CI)


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ACLS incocaine users

Because of the similarity in the cardiovascular effectscaused by cocaine and epinephrine, the administration ofepinephrine to a patient who arrests in a hyperadrenergicstate has been likened to pouring gasoline on a fire.

In theory, vasopressin may offer considerable advantagesover epinephrine in cardiac arrest secondary to cocainetoxicity

The hyperadrenergic state caused by cocaine increasesmyocardial oxygen demand. Epinephrine has the same effect.Vasopressin,onthe otherhand,increasescoronary blood flow,and

therebymyocardialoxygenavailablility


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AHA Statementon Cocaine-Associated ChestPain:

AvoidBetaBlockers, DES

Cocaine increases the risk of myocardial ischemia by raisingoxygendemand (via elevatedheart rate, blood pressure, and cardiac contractility) and loweringsupply (viavasoconstriction) as well as by promotingthrombosis.

In general, the evaluation of patients with chest pain suspected of cocaine use is thesame as for anyone with possible acute coronary syndrome (ACS). Patients should bestratified according to risk factors, such as positive ECG changes and cardiactroponin.

Those at high risk should be assigned to monitored beds. Individuals in whom myocardialinfarction (MI) has been ruled out need only be observed for 9 to 12 hours; their risk ofunderlying coronary artery disease or adverse cardiac events is low.

Beta-BlockersBad,Bare-Metal Good

Use of beta blockersiscontraindicated. Experimental models have shown that when cocaineis present, beta-adrenergic antagonists can lead to reduced coronary blood flow,increased risk of seizure, and increased mortality.

Because only a small proportion of patients with cocaine-associated chest pain areactually having an MI, the established preference for PCI over fibrinolytics is evenstronger. Case reports suggest cocaine mayincrease fibrinolytics risk ofintracranialhemorrhage.

If PCI is performed, the authors suggest that very careful consideration be given to thelikelihood that chronic cocaine users will not comply with long-term antiplatelet therapy.


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Conclusion

Chest pain is the most common chiefcomplaint of cocaine users

High prevalence of CAD and CAA in thispopulation

Up to 10% will have an acute coronary

syndrome

History and EKG may be misleading


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Conclusion

Observe and obtain serial enzymes

Treat keeping in mind the pathophysiology of cocainerelated AMI, avoid BB, use BDZ

Disposition:

- 12h observation period

- Close follow-up for stress-testing

Treat the addiction

Avoid DES and Thrombolysis

cocaine and heart disease

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