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Cocaine-Induced Acute Aortic Dissection
The Journal of Emergency Medicine, Vol. 49, No. 3, pp. e87–e89, 2015 Published by Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2015.02.006
Visual Diagnosis in Emergency Medicine
COCAINE-INDUCED ACUTE AORTIC DISSECTION Rahman Shah, MD,*† Chalak Berzingi, MD,‡ Tai-Hwang M. Fan, MD,*† Raza Askari, MD,* and M. Rehan Khan, MD§ *Section of Cardiovascular Medicine, University of Tennessee, Memphis, Tennessee, †Veterans Affairs Medical Center, Memphis, Tennessee, ‡WVU Heart Institute, Morgantown, West Virginia, and §Virginia Commonwealth University, School of Medicine, Richmond, Virginia Reprint Address: Rahman Shah, MD, University of Tennessee, School of Medicine, Section of Cardiovascular Medicine, Veterans Affairs Medical Center, 1030 Jefferson Avenue, Memphis, TN 38104
On physical examination, the patient was distressed, with a blood pressure of 191/66 mm Hg, and her heart rate was 105 beats/min and regular. On cardiac auscultation, a soft S1, S2, and low-pitched early diastolic murmur along the lower left sternal border were heard. Findings on chest radiographs were normal, and electrocardiogram revealed sinus tachycardia with no significant ST changes. Cardiac enzymes were negative. Urine drug screen was positive for cocaine and cannabinoids. Bedside TTE showed an intimal dissection flap in the ascending aorta consistent with Stanford type-A aortic dissection (Figure 1A [arrow], and Video 1, available online), complicated by aortic regurgitation (AR) (Figure 1B [arrows], and Video 1, available online). After TTE the patient underwent emergent transesophageal echocardiography (TEE), which confirmed the aortic dissection flap (Figure 1C [arrow], and Video 2, available online) and severe AR (Figure 1D [arrows], and Video 2, available online). She was treated with intravenous nitroprusside drip followed by emergent surgery. She underwent successful repair of the ascending aorta and aortic valve replacement. She recovered well and was discharged after 1 week of inpatient care.
INTRODUCTION Cocaine is among the most commonly used illicit recreational drugs worldwide. In the United States, cocaine also leads to more emergency department (ED) visits than any other illicit drug. Acute coronary syndrome is the most common cause of cocaine-associated chest pain (CP). However, acute aortic dissection can also result from the use of cocaine and commonly presents with CP. We report a case of cocaine-induced acute aortic dissection diagnosed by bedside transthoracic echocardiography (TTE). Our case underscores the need for emergency physicians to include aortic dissection in their differential diagnosis of cocaine-associated CP, to prevent unwarranted anticoagulation administration and subsequent morbidity and mortality. CASE REPORT A 30-year-old woman presented to the ED with a chief complaint of severe sharp anterior CP for 2 h. She was a smoker and drank alcohol daily. She admitted to smoking cocaine a few hours prior to the onset of symptoms.
DISCUSSION
Streaming videos: Two brief real-time video clips that accompany this article are available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clips 1 and 2.
Cocaine abuse represents a major public health issue worldwide, as it is one of the most commonly used
RECEIVED: 24 October 2014; FINAL SUBMISSION RECEIVED: 23 January 2015; ACCEPTED: 17 February 2015 e87
e88
R. Shah et al.
Figure 1. (A) Transthoracic echocardiogram in a parasternal long-axis view; patient in the left lateral decubitus position with the phased (sector) array transducer (frequency range of 1 MHz to 5 MHz) in the fourth left intercostal space, immediately adjacent to the sternum, with the index marker oriented toward the right shoulder at approximately the 10–11 o’clock position, at a depth of 16 cm. Aortic dissection is characterized by formation of an ‘‘intimal dissection flap’’ seen as a hyperechoic line extending across the ascending aortic lumen (arrow). (B) Transthoracic echocardiogram with color Doppler imaging in a parasternal long-axis view during diastole showing a large regurgitant jet across the aortic valve, consistent with severe aortic valve regurgitation (arrows). (C) Transesophageal echocardiogram in a mid-esophageal aortic valve long-axis view demonstrating an ‘‘intimal dissection flap’’ seen as a hyperechoic line extending across the ascending aortic lumen (arrow). (D) Transesophageal echocardiogram with color Doppler in a mid-esophageal aortic valve long-axis view during diastole showing a large regurgitant jet across aortic valve, consistent with severe aortic valve regurgitation (arrows).
recreational drugs (1). In the United States, cocaine use accounts for approximately 24% of all ED visits due to drug abuse, making it the most common illicit drugrelated cause of ED visits (1). CP is the most commonly presenting symptom in this patient population. As the work-up and management of CP in cocaine users differ somewhat from that in patients with traditional risk factors, patients presenting with CP, and especially younger patients, should be queried about the use of cocaine (1). Acute coronary syndrome is the most common cardiac condition associated with cocaine use and can occur with all routes of cocaine ingestion (1). However, acute aortic dissection can also result from the use of cocaine and commonly presents with CP (1). Cocaine is a frequent cause of dissection in young, inner-city populations (37% in one report) and occurs more often in those with untreated or poorly controlled hypertension (2). In a large international registry, approximately 0.5% of all aortic dissections were found to be associated with cocaine use (2). Unfortunately, even in larger referral centers, aortic dissection is misdiagnosed in a significant number of patients during the initial evaluation, and is often discovered only at the postmortem examination (3). In fact, in a large retrospective study, 38% of all aortic dissection cases were missed during the initial evaluation (3). In turn, this high
misdiagnosis rate leads to poor outcomes. In one previous study, approximately 21% of patients with aortic dissection were administered anticoagulation therapy, which was found to lead to serious complications or death in 44% of these patients (4). These previous reports, as well as the case presented herein, underscore the need for emergency physicians to include aortic dissection in their differential diagnosis of cocaine-associated CP to prevent unwarranted anticoagulation administration and subsequent morbidity and mortality. Aortic dissection is generally suspected based on history and physical examination and confirmed by imaging (5). Thoracic magnetic resonance imaging, thoracic CT, and multiplane TEE are the preferred methods for evaluating suspected aortic dissection (5). The choice of initial imaging modality depends upon the patient’s hemodynamic status and institutional resources. In patients with severe hemodynamic instability, bedside TEE is the procedure of choice (5). Echocardiography is also useful to assess cardiac complications of dissection, including AR, pericardial effusion, and regional left ventricular systolic function. The initial medical management of aortic dissection is generally aimed at controlling the pain, blood pressure, and heart rate (5). Although no randomized clinical trials have been performed, the current guidelines recommend
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maintaining the heart rate at 60–80 beats/min and the systolic blood pressure at 100–120 mm Hg to decrease the shear forces on the dissected aorta. Intravenous betablocker administration is considered as the first-line therapy, followed by nitroprusside if the systolic blood pressure remains elevated (5). The definitive therapy for type-A aortic dissection is surgery, and it should be treated as a surgical emergency. These patients are at high risk for lifethreatening complications including aortic regurgitation, tamponade, and myocardial infarction, with mortality rates of 35% at 24 h, 50% at 48 h, and 80% by 2 weeks (2,5). REFERENCES 1. Hsue PY, Salinas C, Bolger AF, et al. Acute aortic dissection induced by crack cocaine. Circulation 2002;105:1592–5.
2. Eagle KA, Isselbacher EM, DeSanctis RW. International Registry for Aortic Dissection (IRAD) Investigators. Cocaine-related aortic dissection in perspective. Circulation 2002;105:1529–30. 3. Spittell PC, Spittell JA Jr, Joyce JW, et al. Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990). Mayo Clin Proc 1993;68:642–51. 4. Davis DP, Grossman K, Kiggins DC, et al. The inadvertent administration of anticoagulants to ED patients ultimately diagnosed with thoracic aortic dissection. Am J Emerg Med 2005;23:439–42. 5. Erbel R, Alfonso F, Boileau C, et al. Diagnosis and management of aortic dissection: recommendations of the Task Force on Aortic Dissection, European Society of Cardiology. Eur Heart J 2001;22: 1642–81.
SUPPLEMENTARY DATA Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jemermed.2015.02.006.
Streaming videos: Two brief real-time video clips that accompany this article are available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clips 1 and 2.
http://dx.doi.org/10.1016/j.jemermed.2015.02.006
Visual Diagnosis in Emergency Medicine
COCAINE-INDUCED ACUTE AORTIC DISSECTION Rahman Shah, MD,*† Chalak Berzingi, MD,‡ Tai-Hwang M. Fan, MD,*† Raza Askari, MD,* and M. Rehan Khan, MD§ *Section of Cardiovascular Medicine, University of Tennessee, Memphis, Tennessee, †Veterans Affairs Medical Center, Memphis, Tennessee, ‡WVU Heart Institute, Morgantown, West Virginia, and §Virginia Commonwealth University, School of Medicine, Richmond, Virginia Reprint Address: Rahman Shah, MD, University of Tennessee, School of Medicine, Section of Cardiovascular Medicine, Veterans Affairs Medical Center, 1030 Jefferson Avenue, Memphis, TN 38104
On physical examination, the patient was distressed, with a blood pressure of 191/66 mm Hg, and her heart rate was 105 beats/min and regular. On cardiac auscultation, a soft S1, S2, and low-pitched early diastolic murmur along the lower left sternal border were heard. Findings on chest radiographs were normal, and electrocardiogram revealed sinus tachycardia with no significant ST changes. Cardiac enzymes were negative. Urine drug screen was positive for cocaine and cannabinoids. Bedside TTE showed an intimal dissection flap in the ascending aorta consistent with Stanford type-A aortic dissection (Figure 1A [arrow], and Video 1, available online), complicated by aortic regurgitation (AR) (Figure 1B [arrows], and Video 1, available online). After TTE the patient underwent emergent transesophageal echocardiography (TEE), which confirmed the aortic dissection flap (Figure 1C [arrow], and Video 2, available online) and severe AR (Figure 1D [arrows], and Video 2, available online). She was treated with intravenous nitroprusside drip followed by emergent surgery. She underwent successful repair of the ascending aorta and aortic valve replacement. She recovered well and was discharged after 1 week of inpatient care.
INTRODUCTION Cocaine is among the most commonly used illicit recreational drugs worldwide. In the United States, cocaine also leads to more emergency department (ED) visits than any other illicit drug. Acute coronary syndrome is the most common cause of cocaine-associated chest pain (CP). However, acute aortic dissection can also result from the use of cocaine and commonly presents with CP. We report a case of cocaine-induced acute aortic dissection diagnosed by bedside transthoracic echocardiography (TTE). Our case underscores the need for emergency physicians to include aortic dissection in their differential diagnosis of cocaine-associated CP, to prevent unwarranted anticoagulation administration and subsequent morbidity and mortality. CASE REPORT A 30-year-old woman presented to the ED with a chief complaint of severe sharp anterior CP for 2 h. She was a smoker and drank alcohol daily. She admitted to smoking cocaine a few hours prior to the onset of symptoms.
DISCUSSION
Streaming videos: Two brief real-time video clips that accompany this article are available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clips 1 and 2.
Cocaine abuse represents a major public health issue worldwide, as it is one of the most commonly used
RECEIVED: 24 October 2014; FINAL SUBMISSION RECEIVED: 23 January 2015; ACCEPTED: 17 February 2015 e87
e88
R. Shah et al.
Figure 1. (A) Transthoracic echocardiogram in a parasternal long-axis view; patient in the left lateral decubitus position with the phased (sector) array transducer (frequency range of 1 MHz to 5 MHz) in the fourth left intercostal space, immediately adjacent to the sternum, with the index marker oriented toward the right shoulder at approximately the 10–11 o’clock position, at a depth of 16 cm. Aortic dissection is characterized by formation of an ‘‘intimal dissection flap’’ seen as a hyperechoic line extending across the ascending aortic lumen (arrow). (B) Transthoracic echocardiogram with color Doppler imaging in a parasternal long-axis view during diastole showing a large regurgitant jet across the aortic valve, consistent with severe aortic valve regurgitation (arrows). (C) Transesophageal echocardiogram in a mid-esophageal aortic valve long-axis view demonstrating an ‘‘intimal dissection flap’’ seen as a hyperechoic line extending across the ascending aortic lumen (arrow). (D) Transesophageal echocardiogram with color Doppler in a mid-esophageal aortic valve long-axis view during diastole showing a large regurgitant jet across aortic valve, consistent with severe aortic valve regurgitation (arrows).
recreational drugs (1). In the United States, cocaine use accounts for approximately 24% of all ED visits due to drug abuse, making it the most common illicit drugrelated cause of ED visits (1). CP is the most commonly presenting symptom in this patient population. As the work-up and management of CP in cocaine users differ somewhat from that in patients with traditional risk factors, patients presenting with CP, and especially younger patients, should be queried about the use of cocaine (1). Acute coronary syndrome is the most common cardiac condition associated with cocaine use and can occur with all routes of cocaine ingestion (1). However, acute aortic dissection can also result from the use of cocaine and commonly presents with CP (1). Cocaine is a frequent cause of dissection in young, inner-city populations (37% in one report) and occurs more often in those with untreated or poorly controlled hypertension (2). In a large international registry, approximately 0.5% of all aortic dissections were found to be associated with cocaine use (2). Unfortunately, even in larger referral centers, aortic dissection is misdiagnosed in a significant number of patients during the initial evaluation, and is often discovered only at the postmortem examination (3). In fact, in a large retrospective study, 38% of all aortic dissection cases were missed during the initial evaluation (3). In turn, this high
misdiagnosis rate leads to poor outcomes. In one previous study, approximately 21% of patients with aortic dissection were administered anticoagulation therapy, which was found to lead to serious complications or death in 44% of these patients (4). These previous reports, as well as the case presented herein, underscore the need for emergency physicians to include aortic dissection in their differential diagnosis of cocaine-associated CP to prevent unwarranted anticoagulation administration and subsequent morbidity and mortality. Aortic dissection is generally suspected based on history and physical examination and confirmed by imaging (5). Thoracic magnetic resonance imaging, thoracic CT, and multiplane TEE are the preferred methods for evaluating suspected aortic dissection (5). The choice of initial imaging modality depends upon the patient’s hemodynamic status and institutional resources. In patients with severe hemodynamic instability, bedside TEE is the procedure of choice (5). Echocardiography is also useful to assess cardiac complications of dissection, including AR, pericardial effusion, and regional left ventricular systolic function. The initial medical management of aortic dissection is generally aimed at controlling the pain, blood pressure, and heart rate (5). Although no randomized clinical trials have been performed, the current guidelines recommend
Aortic Dissection
e89
maintaining the heart rate at 60–80 beats/min and the systolic blood pressure at 100–120 mm Hg to decrease the shear forces on the dissected aorta. Intravenous betablocker administration is considered as the first-line therapy, followed by nitroprusside if the systolic blood pressure remains elevated (5). The definitive therapy for type-A aortic dissection is surgery, and it should be treated as a surgical emergency. These patients are at high risk for lifethreatening complications including aortic regurgitation, tamponade, and myocardial infarction, with mortality rates of 35% at 24 h, 50% at 48 h, and 80% by 2 weeks (2,5). REFERENCES 1. Hsue PY, Salinas C, Bolger AF, et al. Acute aortic dissection induced by crack cocaine. Circulation 2002;105:1592–5.
2. Eagle KA, Isselbacher EM, DeSanctis RW. International Registry for Aortic Dissection (IRAD) Investigators. Cocaine-related aortic dissection in perspective. Circulation 2002;105:1529–30. 3. Spittell PC, Spittell JA Jr, Joyce JW, et al. Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990). Mayo Clin Proc 1993;68:642–51. 4. Davis DP, Grossman K, Kiggins DC, et al. The inadvertent administration of anticoagulants to ED patients ultimately diagnosed with thoracic aortic dissection. Am J Emerg Med 2005;23:439–42. 5. Erbel R, Alfonso F, Boileau C, et al. Diagnosis and management of aortic dissection: recommendations of the Task Force on Aortic Dissection, European Society of Cardiology. Eur Heart J 2001;22: 1642–81.
SUPPLEMENTARY DATA Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jemermed.2015.02.006.
Streaming videos: Two brief real-time video clips that accompany this article are available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clips 1 and 2.