One-Year Medical Outcomes and Emergency Department Recidivism After Emergency Department Observation for Cocaine-Associated Chest Pain
Received 28 March 2008; received in revised form 4 June 2008 and 3 July 2008; accepted 15 July 2008. published online 29 September 2008.
Study objective
Chest pain is the most common complaint among cocaine users who present to the emergency department (ED) seeking care, and many hospital resources are applied to stratify cocaine users in regard to future cardiac morbidity and mortality. Little is known about the longitudinal cardiac and noncardiac medical outcomes of cocaine users who have been stratified to an ED observation period after their ED visit. We examine 1-year cardiac outcomes in a low- to intermediate-risk sample of patients with cocaine-associated chest pain in an urban ED, as well as examine ED recidivism at 1 year for cardiac and noncardiac complaints.
Methods
Prospective consecutive cohort study of patients (18 to 60 years) who presented to an urban Level I ED with cocaine-associated chest pain and were risk stratified to low to intermediate cardiac risk. Exclusion criteria were ECG suggestive of acute myocardial infarction, increased serum cardiac markers, history of acute myocardial infarction or coronary artery bypass graft, hemodynamic instability, or unstable angina. Baseline interviews using validated measures of health functioning and substance use were conducted during chest pain observation unit stay and at 3, 6, and 12 months. ED utilization during the study year was abstracted from the medical chart. Zero-inflated Poisson regression analyses were conducted to predict recurrent ED visits.
Results
Two hundred nineteen participants (73%) were enrolled, 65% returned to the ED post–index visit, and 23% returned for chest pain; of these, 66% had a positive cocaine urine screening result. No patient had an acute myocardial infarction within the 1-year follow-up period. Patients with continued cocaine use were more likely to have a recurrent ED visit (P<.001), but these repeated visits were most often related to musculoskeletal pain (21%) and injury (30%), rather than potential cardiac complaints.
Conclusion
Patients with cocaine-associated chest pain who have low to intermediate cardiac risk and complete a chest pain observation unit protocol have a less than 1% rate of myocardial infarction in the subsequent 12 months.
aDepartment of Emergency Medicine, University of Michigan, Ann Arbor, MI
bDepartment of Psychiatry, University of Michigan, Ann Arbor, MI
cDepartment of Emergency Medicine Injury Research Center, Hurley Medical Center, Flint, MI
eCollege of Medicine, University of Arkansas for Medical Sciences, Department of Psychiatry and Behavioral Sciences, Division of Health Services Research, Little Rock, AR
fCentral Arkansas Veterans Healthcare System, Little Rock, AR
Address for correspondence: Rebecca Cunningham, MD, University of Michigan, Injury Research Center, 300 North Ingalls Street, Room 2C40, Ann Arbor, MI 48109-5437; 734-615-3704, fax 734-936-2706
Supervising editor: Judd E. Hollander, MD
Author contributions: All coauthors contributed in conducting this research, writing the article, and approving this final version of the article. RC, MAW, JEW, and RFM were coinvestigators on the grant that funded this work. RC, SO, and MAW developed this article. JEW, SPT, RFM, and BMB reviewed/edited this article. BMB, MAW, RC, JEW and RFM participated in the study design and development of the recruitment protocol. JEW facilitated the research project in the ED. SO contributed to the data abstraction of medical charts. BMB was principal investigator on the grant that funded this work and provided overall supervision for the research presented in this article. RC takes responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Supported by the National Institute on Drug Abuse, RO1 grant DA14343.
Publication dates: Available online September 28, 2008.
ABSTRACT