Randomized, double-blind, placebo-controlled trial of diazepam, nitroglycerin, or both for treatment of patients with potential cocaine-associated acute coronary syndromes.

INTRODUCTION: To the authors' knowledge, treatment of patients with cocaine-associated acute coronary syndromes has not been rigorously investigated in symptomatic patients. OBJECTIVE: To perform a randomized double-blind trial of diazepam, nitroglycerin, or both for treatment of patients with potential cocaine-associated acute coronary syndromes. METHODS: Patients with potential cocaine-associated acute coronary syndromes were randomized to treatment with either diazepam, nitroglycerin, or both every 5 minutes or until symptom resolution. Outcomes were chest pain resolution (measured by visual analog scale), and changes in blood pressure, pulse rate, cardiac output (L/min), cardiac index (L/min/m2), stroke volume (mL/beat), and stroke index (mL/beat/m2) over the 15-minute treatment period. To adjust for seven outcomes using the Bonferroni correction, alpha was set at 0.007. RESULTS: Forty patients were enrolled (diazepam, 12; nitroglycerin, 13; both, 15). Patients had a mean age (+/-SD) of 35.4 (+/-7.5) years; 75% were male. They presented a mean of 5 hours and 37 minutes after cocaine use. Baseline demographics, cocaine use patterns, chest pain characteristics, and initial electrocardiograms were similar for all groups. Chest pain severity improved similarly in the three groups [-33.3 mm (+/-8.0); -30.7 mm (+/-7.1); -33.0 mm (+/-7.9); p = 0.6]. The stroke index decreased during the 15-minute treatment period for all groups (diazepam, -8.7 (+/-3.3); nitroglycerin, -3.1 +/- 2.8; both, -1.8 (+/-3.1) mL/beat/m2; p = 0.03). After adjustment for differences between baseline hemodynamic and cardiac profiles and multiple comparisons, there was no difference in any response to therapy over time for the different treatments. CONCLUSIONS: For treatment of patients with potential cocaine-associated acute coronary syndromes, chest pain resolutions and changes in cardiac performance are not different in patients treated with diazepam or nitroglycerin. In this study, the use of both agents did not offer any advantage over either agent alone.

Cardiac and hemodynamic assessment of patients with cocaine-associated chest pain syndromes.

BACKGROUND: Animal and human experimental studies have yielded conflicted data regarding the effects of cocaine on cardiovascular function. We studied the cardiac and hemodynamic profiles in emergency department chest pain patients following recent cocaine use. METHODS: After obtaining informed consent, emergency department patients who presented with a chief complaint of chest pain and cocaine use within 24 hours of arrival were prospectively enrolled. All patients underwent a structured 40-item history and physical examination and were placed on the IQ Noninvasive Hemodynamic Surveillance System (Renaissance Technology, Inc., Newton, PA), a validated transthoracic cardiac output monitor. The principal measurements obtained included cardiac output, cardiac index, and stroke volume. Data were analyzed with standard descriptive techniques. RESULTS: Twenty-seven patients were enrolled (median age, 37 years [range, 23-54]; 74% male). Patients used a mean of $200 worth of cocaine, usually crack (67%). Patients had a history of tobacco use (82%), prior myocardial infarction (33%), and prior cocaine-associated chest pain (67%). The median (interquartile range; IQR) for the hemodynamic parameters were: mean arterial blood pressure 92 mm Hg (IQR 85-100); heart rate 83/min (IQR 72-98); cardiac output 6.9 L/min (IQR 5.1-7.2); cardiac index 3.2 L/min/m2 (IQR 2.4-4.0); stroke volume 78 mL/beat (IQR 64-93). CONCLUSION: Most emergency department patients with cocaine-associated chest pain have normal cardiac profiles at the time of presentation. The negative inotropic effects of high doses of cocaine observed in animal models do not appear to be present in patients who develop chest pain after using recreational doses of cocaine.