GR2012-01 This is the Heart on Drugs - Dr Mahar

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Cardiovascular complications of substance abuse this is the heart on drugs:

Cardiovascular complications of substance abuse this is the heart on drugs Denis Mahar , MD, Cardiology Contra Costa Regional Medical Center University of California at Davis

Overview:

Overview Cocaine Chest Pain Syndromes Acute Coronary Syndromes Dilated Cardiomyopathy Cocaine Methamphetamine Alcohol Workup and Treatment Prognosis

Cocaine: Historical:

Cocaine: Historical Found in coca plant > 5k years ago 1855: purified by Albert Nieman 1900s: widespread medical use

Cocaine: Historical:

Cocaine: Historical 1914: Harrison Narcotic Act 1960’s – resurgence 1980s - crack

Forms of Cocaine:

Forms of Cocaine Powder Cocaine Intranasal IV Crack Inhaled : aka “freebasing” IV

Cocaine and Abuse:

Cocaine and Abuse Frequency of use: 3rd only to marijuana and methamphetamine 2007: 0.8% of population reported using classic profile = young male 18-20 Of illicit drugs: Most common to precipitate ED visit > 50 yrs old: 2/3 illicit ED drug visits

Cocaine: Cardiovascular Complications:

Cocaine: Cardiovascular Complications Chest pain syndromes Chest wall rhabdomyolysis Myocardial Ischemia and Infarct Aortic Dissection Coronary Artery Aneurysm Cardiomyopathy Myocarditis Dilated Takotsubos

Cocaine: Cardiovascular Complications:

Cocaine: Cardiovascular Complications Arrythmia Pulmonary hypertension Endocarditis Stroke

Cocaine: Physiologic Effects:

Cocaine: Physiologic Effects

Cocaine: Non-ACS Chest Pain:

Cocaine: Non-ACS Chest Pain LVH with increased myocardial 02 demand subendocardial ischemia Chest wall rhabdomyolysis peak CPK without AMI = mean of 300 tendency to present if rhabdo involves chest wall? Kontos et al : Ann Emergency Med June 1999;33:639-45

Cardiac Risk Factors and Cocaine Induced MI:

Cardiac Risk Factors and Cocaine Induced MI 3-6% of patients have acute myocardial infarct Risk of MI 24-fold within 1 hour of ingestion Smokers: elevated risk of cocaine-induced MI No other clear risk factors associated with MI Circulation. 1999;99(21):2737

Cocaine-Related ACS :

Cocaine-Related ACS 479 European ACS patients between 2001-2008 5% with cocaine-related ACS COCAINE NO COCAINE Troponin 42.9 23.4 Ejection fraction 44.5 52.2 Mortality 8.3% 0.8% Carillo et al. Eur Heart Jl 2011;32:1244-1250

Cocaine: Chest Pain Evaluation:

Cocaine: Chest Pain Evaluation High level of suspicion  urine toxicology EKG Serial cardiac enzymes Observation versus admission No testing vs. stress testing vs. cardiac cath

TIMI Risk Score and Cocaine Chest Pain:

TIMI Risk Score and Cocaine Chest Pain Over half of adverse cardiovascular events occur in patients with a TIMI score of 1 or less Conclusion: TIMI risk score has no clinically useful predictive value! Chase et al: Am Jl Emerg Med 2007;25(9):1015-18

Cocaine Associted ACS: EKG:

Cocaine Associted ACS: EKG Young patients = high voltage Coexistent hypertension = LVH Abnormal EKG: > 80% of patients > 40%: ST elevation > 1 mm in 2 contiguous leads N Engl J Med. 1995;333(19):1267

Cocaine Chest Pain: Cardiac Enzymes and Specificity:

Cocaine Chest Pain: Cardiac Enzymes and Specificity Biomarker Cocaine use No Cocaine Use P Value Myoglobin 50% 82% 0.02 CK-MB 75% 88% 0.24 Troponin 94% 94% 1.0 Hollander et al: Am Heart J. 1998;135):245

One Year Medical Outcomes after ED Observation for Cocaine-Associated Chest Pain :

One Year Medical Outcomes after ED Observation for Cocaine-Associated Chest Pain 2 sets of enzymes in 9 hours

Cocaine Related Chest Pain: Treatment Options:

Cocaine Related Chest Pain: Treatment Options ASA Nitroglycerin Benzodiazepines Nitroprusside Labetalol Beta Blockers contraindicated???

ACC Guidelines: Cocaine Chest Pain and ACS:

ACC Guidelines: Cocaine Chest Pain and ACS J Am Coll Cardiol . 2011;57:e15-e367

Beta Blockers for Chest Pain Associated with Recent Cocaine Use:

Beta Blockers for Chest Pain Associated with Recent Cocaine Use SBP by 9 mmHg in beta blocker group No difference in mortality, length of stay, … No meaningful diff. in EKG changes, troponin

Beta Blockers for Chest Pain Associated with Recent Cocaine Use: 3 Year Mortality:

Beta Blockers for Chest Pain Associated with Recent Cocaine Use: 3 Year Mortality

Labetalol and Cocaine Chest Pain:

Labetalol and Cocaine Chest Pain 12 crack cocaine users Double-blind, placebo-controlled Crack cocaine with and without Labetalol 100 and 200 mg Labetalol significantly attenuated the cocaine-induced in heart rate and BP at both doses Pharmacol Biochem Behav . 2000 Feb;65(2):255-9

Carvedilol and Cocaine Chest Pain:

Carvedilol and Cocaine Chest Pain 12 crack cocaine users Double-blind, placebo-controlled Crack cocaine with and without carvedilol 25 and 50 mg Carvedilol attenuated the cocaine-induced in heart rate and BP at 50 mg, but not at 25 mg dose Drug Alcohol Dependence. 2000 Jul 1;60(1):69-76

Substance-Induced Cardiomyopathies :

Substance-Induced Cardiomyopathies Cocaine Methamphetamines Alcohol

PowerPoint Presentation:

Am Jl Card. 2008 Nov 1;102(9):1216-9. 95% Cocaine Users

Faces of Methamphetamines:

Faces of Methamphetamines

Methamphetamines: Overall burden to US economy:

Methamphetamines: Overall burden to US economy $23 billion per year: Health Care costs Drug treatment costs Legal Costs Incarceration Lost Productivity Hazardous waste/clean-up Child removal/placement

PowerPoint Presentation:

107 cases of DCM vs. 114 matched controls Meth users: 3.7-fold odds ratio for DCM 100 nonischemic cardiomyopathies  Meth-induced: EF 26% Non meth-induced: EF 35%

Methamphetamine Abuse and Cardiomyopathy:

Methamphetamine Abuse and Cardiomyopathy Banki et al: Jl Am Coll Card 2003;41(6):1206

Methamphetamine and Cocaine: Proposed Cardiomyopathy Mechanisms :

Methamphetamine and Cocaine: Proposed Cardiomyopathy Mechanisms Catecholaminergic demand: tachycardia, hypertension supply: coronary vasospasm +/- CAD catecholamine myocardial toxicity cellular hypertrophy cellular necrosis MI supply/demand a ccelerated atherosclerosis Hypersensitivity reaction Addiction:102;1204-1211

Overview:

Overview Cocaine Chest Pain Syndromes Acute Coronary Syndromes Dilated Cardiomyopathy Cocaine Methamphetamine Alcohol

Coronary Heart Disease and Alcohol Consumption Health Professional Follow Up Study :

Coronary Heart Disease and Alcohol Consumption Health Professional Follow Up Study 38k male health professionals free of heart disease 12 year follow-up Daily Etoh vs < 1 day a week: relative risk MI 0.63 No difference between 1 vs. > 3 drinks per day No difference in type of Etoh N Engl J Med. 2003;348(2):109

Cardiovascular Effects of Alcohol Consumption: Hypertension:

Cardiovascular Effects of Alcohol Consumption: Hypertension > 2 drinks per day = 2-fold increase in hypertension N Engl J Med. 1977;296(21):1194 Etoh reduction associated with reduction in BP Hypertension. 2001;38(5):1112 Physicians Health Study: hypertensive males  Relative mortality risk: monthly Etoh : 0.86, vs. daily 0.73 Relative CV mortality: monthly Etoh : 0.83, vs. daily 0.56 Arch Intern Med. 2004;164(6):623

Cardiovascular Effects of Alcohol Consumption:

Cardiovascular Effects of Alcohol Consumption Atrial Fibrillation: binge or heavy drinking = increased incidence moderate drinking = no effect Circulation. 2005;112(12):1736 Stroke: Heavy 1.64 Moderate 0.91 Light 0.83 Relative Risk Alcohol JAMA. 2003;289(5):579

Alcoholic Cardiomyopathy: Overview:

Alcoholic Cardiomyopathy : Overview Alcohol abuse = leading cause of secondary nonischemic cardiomyopathy Heart Lung. 1994;23(1):3 Proposed Mechanisms: Ethanol-induced apoptosis Acetaldehyde myocardial toxicity Activation of the renin angiotensin system Alcohol-induced hypertension Chest. 2002;121(5):1638 ACE Gene Polymorphism Ann Intern Med. 2002;137 Nutritional deficiency

Etoh Cardiomyopathy: How much is Way Too Much Alcohol?:

Etoh Cardiomyopathy : How much is Way Too Much Alcohol? 90 grams Etoh per day for > 5 years: One liter of wine Eight 12 ounce beers Half-pint of hard alcohol Most studies quote an average of 15 years Etoh Congest Heart Fail. 2002;8(6):303

Overview:

Overview Cocaine Chest Pain Syndromes Acute Coronary Syndromes Dilated Cardiomyopathy Cocaine Methamphetamine Alcohol Workup and Treatment

Toxin-Induced Cardiomyopathy: Diagnosis:

Toxin-Induced Cardiomyopathy : Diagnosis Symptoms and signs often insidious/subtle May be a paucity of left-sided symptoms often little or no pulmonary edema on CXR! Abdominal fullness and early satiety JVP assessment (cirrhosis vs CHF) Basic labs, ECG, CXR and Echo

Toxin-Induced Cardiomyopathy: Additional Workup to Consider:

Toxin-Induced Cardiomyopathy : Additional Workup to Consider BNP TSH HIV Ferritin ACE level Ischemic workup Angina Older age Multiple risk factors Consider repeat urine toxicology screens

Toxin-Induced Cardiomyopathy: Treatment:

Toxin-Induced Cardiomyopathy : Treatment Abstinence Sodium restriction Standard systolic CHF therapy: ACE or ARB Beta Blocker Aldactone or Epleronone Digoxin Diuretic if needed

Toxin-Induced Cardiomyopathy: Treatment (cont.):

Toxin-Induced Cardiomyopathy : Treatment (cont.) Consider ICD: 3-6 months aggressive medical therapy EF < 35% Documented abstinence??? Consider Biventricular Pacing: ongoing CHF sxs , ICD criteria met + QRS > 120 ms

Overview:

Overview Cocaine Chest Pain Syndromes Acute Coronary Syndromes Dilated Cardiomyopathy Cocaine Methamphetamine Alcohol Workup and Treatment Prognosis

Reversibility of Toxin-Induced Cardiomyopathies: Alcohol:

Reversibility of Toxin-Induced Cardiomyopathies : Alcohol An echocardiographic study of alcoholic cardiomyopathy after total abstinence 5/13 = normalized LV size and EF in 3 months Others: no overall change J Cardiol . 1990;20(3):627

The effect of controlled drinking in alcoholic cardiomyopathy :

The effect of controlled drinking in alcoholic cardiomyopathy 55 men with Etoh cardiomyopathy ≥ 100 g alcohol per day for minimum 10 years 6 month surveillance: Abstinence: average in LVEF 13% Decrease to 20 to 60 g/day: in LVEF 13% Continual Etoh >80 g/day: deterioration in LVEF Nicolás JM et al 2002;136(3):192

Reversibility of Methamphetamine Cardiomyopathy:

Reversibility of Methamphetamine Cardiomyopathy “Reversible Dilated Cardiomypathy Induced by Methamphetamines” Clin Cardiol 1989 Cardiomyopathy Associated With the Smoking of Crystal Methamphetamine JAMA 1991 Cardiac Lesions and their reversibility after long term administration of methamphetamine Forensic Sci Int 1995

PowerPoint Presentation:

No Gad enhancement No Gad enhancement 6 months of medical therapy: EF improved to 65%

Alcohol and Illicit drug Use: Youths age 12-17:

Alcohol and Illicit drug Use: Youths age 12-17

Cocaine Use:

Cocaine Use 2010 = lowest rate of use since 1980’s 37 percent decline in domestic cocaine initiation between 2006 and 2010 Crack use declined by 75% Cocaine seizures on US-Mexican Border down by 28 percent between 2006 and 2010

Past Year Methamphetamine Initiates Age 12 or Older:

Past Year Methamphetamine Initiates Age 12 or Older

QUESTIONS?:

QUESTIONS?

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