Invasive Approach and Revascularization Reduces Morbidity in Cocaine-Associated Non STEMI
Cocaine increases myocardial oxygen demand, thus causing marked vasoconstriction of the coronary arteries and enhances platelet aggregation and thrombus formation, all of which may lead to myocardial infarction (MI). Despite increased awareness of the deleterious consequences of cocaine abuse, it remains a major worldwide health problem. In a recent study, researchers have found that the invasive approaches and revascularization for cocaine-associated Non STEMI are associated with lower morbidity. Overall, invasive management, which included coronary angiography followed by PCI or CABG if needed, lowered the risk of MACE at 6 months by 28% compared with a noninvasive strategy.
The study findings were published in the JACC: Cardiovascular Interventions on March 15, 2021.
In general, current guidelines recommend that patients with cocaine-associated MI should be treated similarly to those with traditional MI or the broader population with MI. However, there have been no randomized, prospective clinical trials to compare optimal treatment strategies for cocaine-associated MI and, available evidence comes primarily from retrospective observational studies, small case series, and case reports. The role of invasive approaches in cocaine-associated NSTEMI remains uncertain. Therefore, researchers of the Harrington Heart and Vascular Institute, USA, conducted a study to determine the impact of the invasive approaches and revascularization in patients with cocaine-associated non–ST-segment elevation myocardial infarction (NSTEMI).
It was a retrospective cohort study of 3,735 patients with NSTEMI and a history of cocaine use from the Nationwide Re-admissions Database from 2016 to 2017. The researchers determined the invasive approach as coronary angiography, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). They also determined the revascularization as PCI and CABG. The primary efficacy outcome was major adverse cardiac events (MACE), and the primary safety outcome was emergent revascularization. They used the appropriate International Classification of Diseases-Tenth Revision codes to identify non-adherence. They also used multivariate logistic regression to generate two propensity-matched cohorts (noninvasive vs invasive and noninvasive vs. revascularization).
Key findings of the study were:
- In the propensity score-matched cohorts, the researchers found that the invasive approach (hazard ratio [HR]: 0.72) and revascularization (HR: 0.54) were associated with a lower rate of MACE, without an increase in emergent revascularization when compared with a non-invasive approach.
- On stratification, they noted that PCI and CABG individually were associated with a lower rate of MACE.
- However, they noted that the emergent revascularization was increased with PCI (HR: 1.78) but not with CABG.
- They observed no significant difference in the rate of MACE among non-adherent patients after PCI and CABG, but, PCI in non-adherent patients was associated with an increase in emergent revascularization (HR: 4.45).
The authors concluded, "Invasive approaches and revascularization for cocaine-associated NSTEMI are associated with lower morbidity. A history of medical nonadherence was not associated with a difference in morbidity but was associated with an increased risk for emergent revascularization with PCI."
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