title: Impact of an abbreviated cardiac enzyme protocol to aid rapid discharge of patients with cocaine-associated chest pain in the clinical decision unit.
abstract: BACKGROUND
  In 2007 there were 64,000 visits to the emergency department (ED) for possible myocardial infarction (MI) related to cocaine use. Prior studies have demonstrated that low- to intermediate-risk patients with cocaine-associated chest pain can be safely discharged after 9-12 hours of observation. The goal of this study was to determine the safety of an 8-hour protocol for ruling out MI in patients who presented with cocaine-associated chest pain.
  
  
  METHODS
  We conducted a retrospective review of patients treated with an 8-hour cocaine chest pain protocol between May 1, 2011 and November 30, 2012 who were sent to the clinical decision unit (CDU) for observation. The protocol included serial cardiac biomarker testing with Troponin-T, CK-MB (including delta CK-MB), and total CK at 0, 2, 4, and 8 hours after presentation with cardiac monitoring for the observation period. Patients were followed up for adverse cardiac events or death within 30 days of discharge.
  
  
  RESULTS
  There were 111 admissions to the CDU for cocaine chest pain during the study period. One patient had a delta CK-MB of 1.6 ng/ml, but had negative Troponin-T at all time points. No patient had a positive Troponin-T or CK-MB at 0, 2, 4 or 8 hours, and there were no MIs or deaths within 30 days of discharge. Most patients were discharged home (103) and there were 8 inpatient admissions from the CDU. Of the admitted patients, 2 had additional stress tests that were negative, 1 had additional cardiac biomarkers that were negative, and all 8 patients were discharged home. The estimated risk of missing MI using our protocol is, with 99% confidence, less than 5.1% and with 95% confidence, less than 3.6% (99% CI, 0-5.1%; 95% CI, 0-3.6%).
  
  
  CONCLUSIONS
  Application of an abbreviated cardiac enzyme protocol resulted in the safe and rapid discharge of patients presenting to the ED with cocaine-associated chest pain.
authors.affiliation: University of Florida, Department of Emergency Medicine, Jacksonville, Florida.
authors.forename: Faheem W
authors.initials: FW
authors.lastname: Guirgis
authors.affiliation: University of Florida, Department of Emergency Medicine, Jacksonville, Florida.
authors.forename: Kelly
authors.initials: K
authors.lastname: Gray-Eurom
authors.affiliation: University of Florida, Department of Emergency Medicine, Jacksonville, Florida.
authors.forename: Teri L
authors.initials: TL
authors.lastname: Mayfield
authors.affiliation: University of Florida, Department of Emergency Medicine, Jacksonville, Florida.
authors.forename: David M
authors.initials: DM
authors.lastname: Imbt
authors.affiliation: University of Florida, Department of Emergency Medicine, Jacksonville, Florida.
authors.forename: Colleen J
authors.initials: CJ
authors.lastname: Kalynych
authors.affiliation: University of Florida College of Medicine, Jacksonville; Center for Health Equity and Quality Research.
authors.forename: Dale F
authors.initials: DF
authors.lastname: Kraemer
authors.affiliation: University of Florida, Department of Emergency Medicine, Jacksonville, Florida.
authors.forename: Steven A
authors.initials: SA
authors.lastname: Godwin
mesh_terms: D000328:Adult; D015415:Biomarkers / Q000097:blood; D002637:Chest Pain / Q000097:blood / Q000139:chemically induced*; D002985:Clinical Protocols; D019970:Cocaine-Related Disorders / Q000150:complications*; D003402:Creatine Kinase / Q000097:blood; D052279:Creatine Kinase, MB Form / Q000097:blood; D005260:Female; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000097:blood / Q000139:chemically induced / Q000175:diagnosis; D012189:Retrospective Studies; D020107:Troponin T / Q000097:blood
chemical_list: D015415:Biomarkers; D020107:Troponin T; D003402:Creatine Kinase; D052279:Creatine Kinase, MB Form