Coronary computerized tomography angiography for rapid discharge of low-risk patients with cocaine-associated chest pain.
BACKGROUND
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.


METHODS
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.


RESULTS
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%).


CONCLUSIONS
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.
Walsh
Kristy
K
Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104-4283, USA.
Chang
Anna Marie
AM
Perrone
Jeanmarie
J
McCusker
Christine
C
Shofer
Frances
F
Collin
Mark
M
Litt
Harold
H
Hollander
Judd
J
D054058:Acute Coronary Syndrome / Q000000981:diagnostic imaging / Q000209:etiology; D000328:Adult; D000787:Angina Pectoris / Q000000981:diagnostic imaging* / Q000209:etiology / Q000401:mortality; D019970:Cocaine-Related Disorders / Q000150:complications* / Q000000981:diagnostic imaging / Q000401:mortality; D003251:Constriction, Pathologic; D017023:Coronary Angiography / Q000379:methods*; D003324:Coronary Artery Disease / Q000150:complications / Q000000981:diagnostic imaging* / Q000401:mortality; D003329:Coronary Vasospasm / Q000000981:diagnostic imaging* / Q000209:etiology / Q000401:mortality; D003937:Diagnosis, Differential; D004562:Electrocardiography; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000000981:diagnostic imaging / Q000209:etiology; D010351:Patient Discharge; D011237:Predictive Value of Tests; D011446:Prospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D013997:Time Factors; D014057:Tomography, X-Ray Computed