May 21, 2009 (San Francisco, California) — Despite the fact that cocaine abuse accounts for approximately 25% of nonfatal myocardial infarctions (MIs) in young people, most addicted individuals presenting to the psychiatric emergency department are not routinely screened for this potentially lethal complication, new research suggests.
A retrospective study presented here at the American Psychiatric Association 162nd Annual Meeting showed that, of 122 cocaine-addicted patients, only 42% received an electrocardiogram (ECG) upon presentation to the emergency department. However, of these individuals, more than 90% had abnormal ECG results — including significant patterns of peak T waves. Further, 4 patients (8.2%) had ST elevations indicative of significant cardiac ischemia.
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| Valerie D'Aurora and John Charooonbara |
"Many cocaine-addicted patients present to the psychiatric emergency department vs a medical emergency department. So this is potentially the only opportunity to screen for cardiac complications. Yet our research suggests psychiatrists are not being vigilant enough with respect to this," Valerie D'Aurora, from St. George's University School of Medicine, in Grenada, the West Indies, told Medscape Psychiatry.
Baseline ECG Should Be Standard Practice
To determine current management of cocaine-addicted patients presenting to the psychiatric emergency department and examine cardiac risk factors in this patient population, the researchers conducted a chart review of 122 patients with a diagnosis of cocaine dependence.
Of these individuals, 52 (42.6%) received an ECG and 4 (3.3%) had measurement of cardiac bioenzymes, including troponin and creatine kinase (CK)-MB. Among subjects who did receive an ECG, the most common findings were:
- Nonspecific ST-T wave changes in 15 (31.2%) patients.
- Peaked T waves in 23 (47.9%) patients.
- Early afterdepolarizations in 19 (39.6%) patients.
- ST elevations in 2 or more contiguous leads in 4 (8.3%) patients. However, the investigators note there were no baseline ECGs available for comparison to determine the acuity of changes.
The researchers also note ECGs were conducted, on average, 2 days after patients presented to the emergency department, with follow-up in only 2 (1.6%) patients. This, in spite of the fact that research shows the greatest risk for MI is 1 hour after cocaine use and is independent of dose, frequency, or routine. They also note that even trace amounts of cocaine in urine indicate the need to implement acute coronary syndrome (ACS) protocol.
"We're lucky if these patients get to the emergency department an hour after use, so they need to get an ECG immediately upon presentation," said Ms. D'Aurora.
Few Patients Assessed for Cardiac Risk Factors
Concomitant alcohol dependence was identified in 40 (32.8%) patients, and 81 (66.4%) individuals were nicotine dependent. In addition, 63 (51.6%) were also dependent on opioids and 26 (21%) on benzodiazepines.
When researchers analyzed data on additional cardiac risk factors, they found that this information, including family history of heart disease, hypertension, obesity, diabetes, and abdominal aortic aneurysm, were documented in only 21.3% of study subjects.
In light of these findings, Ms. D'Aurora and colleagues have developed an algorithm for individuals presenting to the psychiatric emergency department with a high suspicion of cocaine abuse to optimize patient care that includes a baseline ECG within 1 hour of presentation to the emergency department.
"What was really surprising about this study is what is not being done. When these patients have positive ECGs, they are not being referred to cardiologists per the ACS guidelines."
Regardless of whether they present to a medical emergency department or psychiatric emergency, they should be assessed for potential cardiac complications, said Ms. D'Aurora.
"With all of the other things that go on in a psychiatric emergency department, I think the importance of this is probably underrated. But even if it just means taking out your stethoscope and listening to the heart or taking a pulse, cardiac assessment in these patients needs to become part of the standard management in the psychiatric department," she said.
High Index of Suspicion
Asked by Medscape Psychiatry to comment on the study, Mark Willenbring, MD, director of the division of treatment and recovery research at the National Institute on Alcohol Abuse and Alcoholism, said the findings highlight the need to have a higher index of suspicion for cardiac complications in cocaine addiction and intoxication.
"We've known for a long time that this patient group is at particular risk of cardiac complications. This study suggests that there are significant cardiac abnormalities that are being missed in patients who are triaged to a psychiatric service, and I suspect that's quite likely," said Dr. Willenbring.
"That said, I'm not a cardiologist, and so I don't know if providing a routine ECG in all of these patients is necessary or cost-effective, but I do think one should always have a very high index of suspicion and investigate for the possible presence of cardiac abnormalities with a lower threshold in these patients than you would with others," he added.
Source : http://www.medscape.com/viewarticle/703149?sssdmh=dm1.474949&src=nldne
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