Diagnóstico y pronóstico de la cardiopatía isquémica asociada al consumo de cocaína

Abstract

Background: Recreational cocaine consumption in European countries has increased in recent years, and Spain is one of the main cocaine-using country in Europe. Cocaine has several effects on the cardiovascular system, being a trigger for Acute Coronary Syndrome (ACS). Methods: A prospective observational study was conducted between 2001 and 2014 in patients admitted to our coronary unit younger than 50 years old who suffered from an ACS. A detailed history of cocaine use and a determination of the metabolites of cocaine in urine were performed. Our working hypothesis was "Recent cocaine use associated with an acute coronary syndrome (ACS-ACC) has a deleterious short- and long-term prognostic impact on ACS not due to cocaine. " Recent cocaine use associated with ACS (ACS-ACC) was defined as positive determination of cocaine metabolites in urine or admitting recent cocaine consumption prior to admission in the anamnesis in those patients who suffered an ACS. Results: 1002 patients younger than 50 years with ACS were included. 15. 1% reported having consumed cocaine at least once in their lifetime (41. 7% were former users, 33. 1% occasional users and 25. 2% current users). We observed an increase in prevalence of cocaine use from 6. 6% in 2002 to a peak of 21. 7% and 20. 5% in 2008 and 2009. Determination of metabolites was obtained in 864 patients (86. 2%), being positive in 52 (6%). A total of 59 patients (6. 8%) presented a ACS-ACC. Patients with a history of cocaine use had a higher consumption of other substances, such as tobacco, alcohol, and other. Higher frequency of ACS with ST segment elevation was observed in cocaine users. The group of patients with ACS-ACC received less treatment with beta-blockers in the acute phase (40. 7 vs 78. 1%, p 0. 001) and also at discharge (59. 6 vs 84. 2%, p 0. 001). Differences in reperfusion treatments for patients with ACS-ACS were not observed in spite of a lower lower use of drug-eluting stents (17. 6 vs 34. 5%, p=0. 043). During hospitalization, patients with ACS-ACC presented higher complications such as ventricular tachycardia (16. 9 vs 4. 7%, p 0. 001), cardiogenic shock (6. 8% vs 2. 2%, p=0. 032) and acute intraventricular conduction abnormalities (6. 8 vs 1. 5%,p=0. 004) as well as a trend towards a higher hospital mortality (3. 4 vs 1. 0, p=0. 097). Higher mortality in patients with ACS-ACC was observed (12. 3% vs 5%, p=0. 020) and also cardiac mortality (7% vs. 1. 2%, p 0. 001). The combined event of death, infarction or revascularization (MACE) was also higher in ACS-ACC (35. 1 vs 18. 8%, p = 0. 003). Coxx survival multivariate analysis adjusted for killip classification and treatment at discharge showed a HR of 2. 126 ([IC 0. 926-4. 881], p = 0. 075) for overall mortality, 4,038 ([1,151-14,168], p = 0. 029) for cardiac mortality and 2. 015 ([1. 247-3. 255], p=0. 004) for MACE. Conclusions: The treatment given in patients with ACS-ACC differs from patients with ACS-NACC, with lower proportion of beta-blocking drugs being used during admission and at discharge as well as a higher implantation of drug-eluting stents in coronary intervention procedures. Patients with ACS-ACC have a worse outcome at follow-up than patients with ACS-NACC with more incidence of stent thrombosis, higher mortality (overall and especially cardiac cause) and higher ischemic events, mainly miocardial infarction. Our hypothesis is confirmed in our setting, and patients with acute coronary syndrome associated with recent cocaine use have worse hospital prognosis with greater number of hospital complications, worse long-term prognosis with higher mortality and myocardial infarction at follow-up.

Date of Award	15 Sept 2017
Original language	Spanish
Awarding Institution	Germans Trias i Pujol University Hospital
Supervisor	Antonio Bayes Genis (Director)