Medical Minute: Validation of a Brief Observation Period for Patients with Cocaine-Associated Chest Pain

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September 8, 2014 by dailybolusoflr

By: Wing Province, MD

Question: Why do we discharge cocaine chest pain patients so quickly in the ED?
NEJM: Validation of a Brief Observation Period for Patients with Cocaine-Associated Chest Pain. 
Weber JE, Shofer FS, Larkin GL, Kalaria AS, Hollander JE. 
N Engl J Med. 2003 Feb 6;348(6):510-7. 
Departments of Emergency Medicine, University of Michigan, Ann Arbor, and Hurley Medical 
Center, Flint, Mich. 
This prospective study evaluated whether discharging cocaine-associated chest pain patients with no evidence of ischemia after a 12-hour observation period could be done safely with a very low rate of complications. Previous retrospective studies showed safety and cost-effectiveness, 
even though the risk of MI is 24 times the base-line risk during the hour after cocaine use. 
This study shows that if the patient has not had their MI during a 9 to 12 hour observation period, that they are unlikely to manifest an MI beyond this time frame and are safe for discharge. 
• 344 patients with cocaine-associated chest pain were evaluated with 42 (12%) directly admitted to the hospital, resulting in a302 patient cohort. 
• At 30 days, none of the patients died of a cardiovascular event. 
• At 30 days, 4 of the 256 patients had a non-fatal MI
• All four nonfatal MIs occurred in patients who continued to use cocaine. 

• There was a very low risk of death or MI during the 30 days after discharge for patients with cocaine-associated chest pain who do not have evidence of ischemia or cardiovascular complications over a 9 to 12 hour period in a chest-pain observation unit. 

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