Walsh Kristy, Chang Anna Marie, Perrone Jeanmarie, McCusker Christine, Shofer Frances, Collin Mark, Litt Harold, Hollander Judd
Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104-4283, USA.
J Med Toxicol. 2009 Sep;5(3):111-9. doi: 10.1007/BF03161220.
Most patients presenting to emergency departments (EDs) with cocaine-associated chest pain are admitted for at least 12 hours and receive a "rule out acute coronary syndrome" protocol, often with noninvasive testing prior to discharge. In patients without cocaine use, coronary computerized tomography angiography (CTA) has been shown to be useful for identifying a group of patients at low risk for cardiac events who can be safely discharged. It is unclear whether a coronary CTA strategy would be efficacious in cocaine-associated chest pain, as coronary vasospasm may account for some of the ischemia. We studied whether a negative coronary CTA in patients with cocaine-associated chest pain could identify a subset safe for discharge.
We prospectively evaluated the safety of coronary CTA for low-risk patients who presented to the ED with cocaineassociated chest pain (self-reported or positive urine test). Consecutive patients received either immediate coronary CTA in the ED (without serial markers) or underwent coronary CTA after a brief observation period with serial cardiac marker measurements. Patients with negative coronary CTA (maximal stenosis less than 50%) were discharged. The main outcome was 30-day cardiovascular death or myocardial infarction.
A total of 59 patients with cocaine-associated chest pain were evaluated. Patients had a mean age of 45.6 +/- 6.6 yrs and were 86% black, 66% male. Seventy-nine percent had a normal or nonspecific ECG and 85% had a TIMI score <2. Twenty patients received coronary CTA immediately in the ED, 18 of whom were discharged following CTA (90%). Thirty-nine received coronary CTA after a brief observation period, with 37 discharged home following CTA (95%). Six patients had coronary stenosis >or=50%. During the 30-day follow-up period, no patients died of a cardiovascular event (0%; 95% CI, 0-6.1%) and no patient sustained a nonfatal myocardial infarction (0%; 95% CI, 0-6.1%).
Although cocaine-associated myocardial ischemia can result from coronary vasoconstriction, patients with cocaine associated chest pain, a non-ischemic ECG, and a TIMI risk score <2 may be safely discharged from the ED after a negative coronary CTA with a low risk of 30-day adverse events.
大多数因可卡因相关性胸痛就诊于急诊科（ED）的患者会住院至少12小时，并接受“排除急性冠状动脉综合征”方案，通常在出院前进行无创检查。在未使用可卡因的患者中，冠状动脉计算机断层扫描血管造影（CTA）已被证明有助于识别一组心脏事件低风险且可安全出院的患者。目前尚不清楚冠状动脉CTA策略在可卡因相关性胸痛中是否有效，因为冠状动脉痉挛可能是部分缺血的原因。我们研究了可卡因相关性胸痛患者冠状动脉CTA结果为阴性是否能识别出可安全出院的亚组患者。
我们前瞻性评估了冠状动脉CTA对因可卡因相关性胸痛（自我报告或尿检测阳性）就诊于急诊科的低风险患者的安全性。连续患者在急诊科接受即时冠状动脉CTA（无系列标志物）或在经过简短观察期并进行系列心脏标志物测量后接受冠状动脉CTA。冠状动脉CTA结果为阴性（最大狭窄小于50%）的患者出院。主要结局是30天心血管死亡或心肌梗死。
共评估了59例可卡因相关性胸痛患者。患者平均年龄为45.6±6.6岁，86%为黑人，66%为男性。79%的患者心电图正常或非特异性，85%的患者TIMI评分<2。20例患者在急诊科立即接受冠状动脉CTA，其中18例在CTA后出院（90%）。39例在经过简短观察期后接受冠状动脉CTA，37例在CTA后出院回家（95%）。6例患者冠状动脉狭窄≥50%。在30天随访期内，无患者死于心血管事件（0%；95%CI，0 - 6.1%），也无患者发生非致命性心肌梗死（0%；95%CI，0 - 6.1%）。
尽管可卡因相关性心肌缺血可由冠状动脉收缩引起，但对于有可卡因相关性胸痛、非缺血性心电图且TIMI风险评分<2的患者，冠状动脉CTA结果为阴性后可从急诊科安全出院，30天不良事件风险较低。
