Clinical Decisionmaking

Routine hospitalization of all cocaine users seen in the ER for cardiac symptoms may not be warranted

Cocaine users who end up in the hospital emergency department (ED) typically complain of chest pain, shortness of breath, dizziness, or heart palpitations or other symptoms suggestive of acute cardiac ischemia (ACI): heart attack or unstable angina. However, few cocaine-using ED patients ultimately prove to have ACI and need to be hospitalized, according to the results of a multicenter study supported by the Agency for Healthcare Research and Quality (HS07360). Of the 3 percent of 10,689 ED patients with ACI symptoms who were cocaine users, only 2.1 percent proved to have ACI (0.7 percent had a heart attack, and 1.4 percent had unstable angina).

Harry P. Selker, M.D., M.S.P.H., of Tufts University School of Medicine, was principal investigator of this AHRQ-funded study. Dr. Selker and his colleagues examined the actual incidence of ACI among cocaine-using patients who arrived at the EDs of 10 study hospitals with symptoms of ACI. Patients with cocaine-induced complaints were as likely to be admitted to the coronary care unit as non-cocaine users (14 vs. 18 percent), yet they were much less likely to have confirmed unstable angina (1.4 vs. 9.3 percent) or AMI (0.7 vs. 8.6 percent). More research is needed on the best and most cost-effective approach, short of routine hospital admission, for triaging patients with cocaine-associated symptoms, conclude the researchers.

The two cocaine-using patients who had heart attacks had presenting electrocardiograms (ECGs) consistent with ACI. None of the 37 cocaine users with cocaine-associated symptoms other than chest pain and no ECG abnormalities proved to have ACI. For these extremely low-risk patients, resolution of symptoms after the administration of a benzodiazepine—a minor tranquilizer—and the absence of ACI on repeat ECG may support ED discharge with referral for addiction counseling, conclude the authors of the study.

See "Acute cardiac ischemia in patients with cocaine-associated complaints: Results of a multicenter trial," by James A. Feldman, M.D., Susan S. Fish, Pharm.D., M.P.H., Joni R. Beshansky, R.N., M.P.H., and others, in the November 2000 Annals of Emergency Medicine 36(5), pp. 469-476.

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