Outcomes in patients with history of cocaine use presenting with chest pain to the emergency department: Insights from the Nationwide Emergency Department Sample 2016-2018.

OBJECTIVES: Cocaine use (CU) related chest pain (CP) is a common cause of emergency department (ED) visits in the United States. However, information on disposition and outcomes in these patients is scarce. We conducted a nationwide study to assess disposition from ED, hospitalization rates, in-hospital outcomes, and health care costs in patients with history of CU who presented to the ED with CP. METHODS: We queried the Nationwide Emergency Department Sample database from 2016-2018 for adult patients with CU presenting to the ED with CP. International Classification of Diseases, Tenth Revision codes were used to identify study patients. RESULTS: We identified 149,372 patients. The majority were male (76%), presented to metropolitan centers (91.3%), and had a high prevalence of cardiovascular risk factors (48.1% with hypertension, 24.4% with coronary artery disease, 18.2% with diabetes) and psychiatric illnesses (21%). Overall, 21.4% of patients were hospitalized, 68.6% were discharged from ED and 6.6% left against medical advice. Patients requiring admission were older (51.8 vs 45.0; P < 0.0001) and had a higher prevalence of coronary artery disease, peripheral arterial disease, hypertension, diabetes, and chronic kidney disease. Of those admitted, 45.7% were diagnosed with myocardial infarction (MI), constituting 9.7% of the total study population. Over 80% of these patients underwent coronary angiography and 38.6% had coronary intervention. Mortality was 1.2%. CONCLUSION: CU patients who present to ED are predominantly male, are from lower economic strata, and have significant comorbidity burden. One in 5 patients requires hospitalization and has more prevalent cardiovascular risk factors and comorbidities. In-hospital mortality is low, but incidence of MI and subsequent invasive procedures is high. CU may be considered a cardiac risk factor as it is associated with high rates of in-hospital MI.

Spontaneous coronary artery perforation secondary to a sirolimus-eluting stent infection.

Coronary stent infection is exceedingly rare despite the widespread use of percutaneous coronary intervention (PCI). The utilization of drug-eluting stents (DES) may have a higher theoretical risk of infection due to their local immunosuppressant effect. Vigilance in suspecting stent infection is important, as the associated mortality rate is approximately 50%. We discuss the case of a patient who presented with an infected DES 2 weeks after implantation which led to spontaneous Type II coronary perforation. The perforation was sealed with prolonged balloon inflation, and the patient was treated with intravenous antibiotics. This is the first reported case of a patient with a stent infection who presented with a spontaneous coronary perforation.

Effects of beta-blockers on implantable cardioverter defibrillator therapy and survival in the patients with ischemic cardiomyopathy (from the Multicenter Automatic Defibrillator Implantation Trial-II).

This study examined the effects of beta blockers on (1) appropriate implantable cardioverter defibrillator (ICD) therapy for ventricular tachycardia (VT) or ventricular fibrillation (VF), (2) inappropriate ICD therapy for atrial fibrillation or supraventricular tachycardia, and (3) survival in 691 patients who received ICDs in the Multicenter Automatic Defibrillator Implantation Trial-II. The study population involved 258 patients who were not receiving beta blockers and 433 who were receiving metoprolol (n = 192), atenolol (n = 58), or carvedilol (n = 182). Patients receiving beta blockers were divided into the upper quartile and lower 3 quartiles of the drug doses they were taking. Patients receiving the higher doses of beta blockers (those in the top quartile of doses) had a significant reduction in the risk for VT or VF requiring ICD therapy compared with patients not receiving beta blockers (hazard ratio 0.48, p = 0.02). The frequency of inappropriate ICD therapy for supraventricular tachyarrhythmias was not significantly different among the 3 treatment groups (p = 0.32). Beta-blocker use at the 2 dosage levels was associated with significant improvement in survival compared with the nonuse of beta blockers (hazard ratios 0.42 to 0.44, p <0.01). In conclusion, beta blockers reduce the risk for VT or VF and improve survival in ICD-treated patients with ischemic cardiomyopathy.