Improvement in clinical outcomes of patients with heart failure and active cocaine use after β‐blocker therapy

Background

Cocaine use has a high prevalence in the United States and can be associated with significant cardiovascular disease, even in asymptomatic users. β‐Adrenergic receptor hyperactivation is the underlying pathophysiologic pathway of cocaine cardiotoxicity. β‐Blocker therapy is controversial in patients with active cocaine use.

Hypothesis

β‐Blocker therapy is associated with clinical improvement in patients with heart failure despite active cocaine use.

Methods

In a single‐center, retrospective chart analysis, patients with newly diagnosed heart failure and active cocaine use who had been started on β‐blocker therapy were reviewed. The New York Heart Association (NYHA) functional class and the left ventricular ejection fraction (LVEF) were recorded at baseline and after 12 monthsnthsnths of β‐blocker use. Patients were excluded if they had been on prior β‐blocker therapy, had other reasons for volume overload, had chronic kidney disease stages G4 or G5, or had a life expectancy <12 months.

Results

Thirty‐eight patients were identified; most were African American males. A statistically significant improvement was found in both NYHA functional class (P < 0.0001) and LVEF (P < 0.0001) after 12 months of β‐blocker therapy. No major adverse cardiovascular events occurred in this population.

Conclusions

β‐Blocker use in cocaine users with heart failure with a reduced ejection fraction is associated with a lower NYHA functional class and a higher LVEF at 12‐month follow‐up. No major adverse cardiovascular events were observed.     

The relationship between glycosylated hemoglobin and myocardial perfusion imaging

Background:

The relationship between long‐term glucose control (measured by glycosylated hemoglobin [HgbA1C]) and myocardial perfusion imaging (MPI) abnormalities in symptomatic diabetic patients has not been studied.

Hypothesis:

We hypothesized that diabetic patients with poorly controlled HgbA1C would have more abnormal MPI compared to both patients without diabetes and diabetic patients with tighter glycemic control.

Methods:

This was a retrospective evaluation of 1037 consecutive patients referred for MPI. All patients completed a 1‐day MPI protocol. The electronic medical records were accessed for demographics and relevant medical history.

Results:

Diabetic patients had a higher risk of abnormal MPI (including ischemia, infarction, and mixed ischemia/infarction) compared to nondiabetic patients (relative risk [RR] = 1.77). The populations with suboptimal (HgbA1C ≥7%) and poor (HgbA1C ≥8%) glycemic control had significantly higher risk of abnormal MPI (RR = 1.78 and 2.17, respectively) compared to nondiabetic patients. Coronary angiography supported the MPI results; 66% of diabetic patients had coronary artery disease (CAD), which was higher than the 53% of patients without diabetes found to have CAD.

Conclusions:

The importance of strict glycemic control to reduce cardiovascular complications in diabetic patients is well known. Our study shows a significantly higher risk of abnormal MPI and CAD in diabetic patients with suboptimal and poor long‐term glycemic control, further emphasizing the need for aggressive risk factor modification to minimize vascular complications from DM. Clin. Cardiol. 2012 doi: 10.1002/clc.22028 The authors have no funding, financial relationships, or conflicts of interest to disclose.     

Electrocardiographic left ventricular hypertrophy predicts recurrence of atrial arrhythmias after catheter ablation of paroxysmal atrial fibrillation

Background

Left ventricular hypertrophy (LVH) is an independent predictor of new‐onset atrial fibrillation. Whether LVH can predict the recurrence of arrhythmia after radiofrequency catheter ablation (RFCA) in patients with paroxysmal atrial fibrillation (PAF) remains unclear.

Hypothesis

PAF patients with baseline‐electrocardiographic LVH has a higher recurrence rate after RFCA procedure compared with those without LVH.

Methods

A total of 436 patients with PAF undergoing first RFCA were consecutively enrolled and clustered into 2 groups based on electrocardiogram (ECG) findings: non‐ECG LVH (218 patients) and ECG LVH (218 patients). LVH was characterized by the Romhilt‐Estes point score system; the score ≥5points were defined as LVH.

Results

At 42 months' (interquartile range, 18.0–60.0 months) follow‐up after RFCA, 151 (69.3%) patients in the non‐ECG LVH group and 108 (49.5%) patients in the ECG LVH group maintained sinus rhythm without using antiarrhythmic drugs (P < 0.001). Patients with ECG LVH tended to experience a much higher prevalence of stroke and recurrence of atrial arrhythmia episodes compared with those without ECG LVH (log‐rank P < 0.001). Multivariate analysis found the presence of ECG LVH and left atrial diameter to be independent risk factors for recurrence after adjusting for confounding factors.

Conclusions

The presence of ECG LVH was a strong and independent predictor of recurrence in patients with PAF following RFCA.     

Evaluating the Prognostic Value of Positron‐Emission Tomography Myocardial Perfusion Imaging Using Automated Software to Calculate Perfusion Defect Size

Background:

Myocardial perfusion imaging by positron‐emission tomography (PET MPI) is regarded as a valid technique for the diagnosis of coronary artery disease (CAD), but the incremental prognostic value of PET MPI among individuals with known or suspected CAD is not firmly established.

Hypothesis:

Myocardial perfusion defect sizes as measured by PET MPI using automated software will provide incremental prognostic value for cardiac and all‐cause mortality.

Methods:

This study included 3739 individuals who underwent rest‐stress rubidium‐82 PET MPI for the evaluation of known or suspected CAD. Rest, stress, and stress‐induced myocardial perfusion defect sizes were determined objectively by automated computer software. Study participants were followed for a mean of 5.2 years for cardiac and all‐cause mortality. Cox proportional hazards models were developed to evaluate the incremental prognostic value of PET MPI.

Results:

A strong correlation was observed between perfusion defect sizes assessed visually and by automated software (r = 0.76). After adjusting for cardiac risk factors, known CAD, noncoronary vascular disease, and use of cardioprotective medications, stress perfusion defect size was strongly associated with cardiac death (P < 0.001). Rest perfusion defects demonstrated a stronger association with cardiac death (P < 0.001) than stress‐induced perfusion defects (P = 0.01), yet both were highly significant. Similar patterns held for all‐cause death.

Conclusions:

The current study is the largest to date demonstrating PET MPI provides incremental prognostic value among individuals with known or suspected CAD. Automated calculation of perfusion defect sizes may provide valuable supplementary information to visual assessment. This work was partially funded by a predoctoral fellowship grant awarded to the first author by the American Heart Association's Founders' Affiliate. Additional funding was provided by Niagara Falls Memorial Medical Center, Positron Corporation, the University at Buffalo, and Niagara University. The authors have no other funding, financial relationships, or conflicts of interest to disclose.     

Diagnostic value of single‐photon–emission computed tomography in severe central nervous system involvement of systemic lupus erythematosus: A case‐control study

Objective

To evaluate the diagnostic value of single‐photon–emission computed tomography (SPECT) in severe central nervous system (CNS) involvement of systemic lupus erythematosus (SLE).

Methods

Forty‐three patients with SLE, including 22 with CNS‐SLE and 21 with non–CNS‐SLE, underwent SPECT and magnetic resonance imaging (MRI) examinations. SPECT was repeated 1–2 months after treatment in patients with abnormal findings.

Results

SPECT and MRI abnormalities were detected in 20 (90.9%) and 10 (45.5%) of the 22 patients with CNS‐SLE, respectively (P < 0.01). For 4 patients with cerebral infarction or hemorrhage, SPECT was equally as sensitive as MRI (100%). For the patients with CNS‐SLE with diffuse presentations, SPECT was more sensitive than MRI in revealing abnormalities (16 [88.9%] of 18 patients versus 6 [33.3%] of 18 patients; P < 0.01). In 19 (95.0%) patients, the abnormal SPECT finding manifested as moderate to severe perfusion defect (15 in frontal lobe, 11 in parietal lobe, 11 in basal ganglia, 3 in temporal lobe, and 17 in multiple regions). Although mild perfusion defect was also detected in 4 (19.0%) of the patients with non–CNS‐SLE, it only involved a single region and spared the frontal and parietal lobes. Repeated SPECT after treatment showed that perfusion defect had improved significantly or even disappeared in 11 (84.6%) of 13 patients with diffuse CNS‐SLE with abnormal findings before treatment.

Conclusion

Moderate to severe perfusion defect in SPECT involving multiple regions, especially in the frontal and parietal lobes and basal ganglia, in patients with lupus suggests CNS involvement. SPECT is more sensitive than MRI in revealing damage in diffuse CNS‐SLE, and is useful in followup, especially for monitoring disease severity and guiding treatment.

     

Sociodemographic and drug use severity differences between medical marijuana users and non‐medical users visiting the emergency department

Background and Objectives

The purpose of this study is to extend what is known about medical marijuana and non‐medical marijuana users who visit the emergency department (ED) by exploring differences in their sociodemographic characteristics and their drug‐related problem severity.

Methods

Of 292 consecutively enrolled exclusive marijuana‐only users visiting the ED for any reason, 37% (n = 107) reported using marijuana on the advice of a medical doctor, and 63% (n = 185) reported that they did not use it under the advice of a medical doctor (ie, non‐medical user). Participants denied using any other drug with the exception of alcohol. Participants completed the Addiction Severity Index‐Lite which provided composite and individual items related to drug use problems, psychiatric problems, medical problems, and alcohol use problems. Self‐efficacy for avoiding drug use and sociodemographic characteristics were also collected.

Results

In a multivariate model, compared to non‐medical marijuana users, medical users reported a higher frequency of days of use, more money spent on marijuana, and lower readiness to change use of marijuana, yet lower frequency of drug problems and tended to be low‐risk versus moderate‐severe risk users. Medical marijuana use was associated with a greater number of days of psychological problems.

Discussion and Conclusions

Results for medical marijuana users might be interpreted as consistent with that of routine, self‐administered treatment for medical or psychological problems.

Scientific Significance

Results suggest behavioral health interventions in acute care settings should consider treating non‐medical marijuana users differently than medical users due to the greater drug‐related problems associated with non‐medical use. (Am J Addict 2016;25:385–391)     

Positive vasodilator stress ECG with normal myocardial perfusion imaging and its correlation with coronary angiographic findings in African Americans and Hispanics

Background:

Ischemic electrocardiographic (ECG) changes during vasodilator stress testing (VST) in the presence of abnormal myocardial perfusion imaging (MPI) are uncommon and are associated with presence of multivessel coronary artery disease (CAD). However, there is a paucity of data regarding the significance of ischemic ECG changes during VST with normal MPI in general, and especially among African Americans and Hispanics.

Hypothesis:

Ischemic changes during VST with normal MPI are associated with significant CAD.

Methods:

A retrospective review was done of 2945 patients undergoing VST.

Results:

Only 20 patients (0.7%) had positive ECG changes with normal MPI. Their demographics were: 60% Hispanic, 40% African American; 85% female; mean age 63 ± 11 years; history of hypertension 80%, diabetes 50%, and dyslipidemia 75%; smokers 30%; atypical chest pain 60%, and typical chest pain 40%. Of these 20 patients, 12 patients underwent coronary angiography. All 12 had significant CAD; nine (75%) had multivessel disease and 3 (25%) had single‐vessel disease. Prevalence of clinical variables and risk factors for CAD were similar among both the groups who did and did not undergo coronary angiography.

Conclusions:

Among African Americans and Hispanics, ischemic ECG changes during VST with normal MPI are likely to be associated with significant CAD and may warrant coronary angiography to assess presence and extent of CAD. Copyright © 2010 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

Heterogeneity of Stimulant Dependence: A National Drug Abuse Treatment Clinical Trials Network Study

We investigated the presence of DSM‐IV subtyping for dependence on cocaine and amphetamines (with versus without physical dependence) among outpatient stimulant users enrolled in a multisite study of the Clinical Trials Network (CTN). Three mutually exclusive groups were identified: primary cocaine users (n = 287), primary amphetamine users (n = 99), and dual users (cocaine and amphetamines; n = 29). Distinct subtypes were examined with latent class and logistic regression procedures. Cocaine users were distinct from amphetamine users in age and race/ethnicity. There were four distinct classes of primary cocaine users: non‐dependence (15%), compulsive use (14%), tolerance and compulsive use (15%), and physiological dependence (tolerance, withdrawal, and compulsive use; 56%). Three distinct classes of primary amphetamine users were identified: non‐dependence (11%), intermediate physiological dependence (31%), and physiological dependence (58%). Regardless of stimulants used, most female users were in the most severe or the physiological dependence group. These results lend support for subtyping dependence in the emerging DSM‐V.     

Vectorcardiogram synthesized from the 12-lead electrocardiogram to image ischemia

Background

Knowledge of the location and size of ischemic myocardium at risk for infarction could impact prehospital patient triage and reperfusion therapy. The 12-lead electrocardiogram (ECG) can roughly estimate ischemia size; however, individual precordial ECG leads are at different distances from the left ventricle (LV) and certain LV walls have greater effects on the ECG. Vectorcardiographic corrected orthogonal lead systems can display the magnitude and direction of the ST-segment “injury current” vector in 3-dimensional space. We assessed whether the vectorcardiographic ST-vector direction and magnitude derived from the ECG by the inverse-Dower method can estimate the location and size of ischemia.

Methods and Results

Thirty-two patients underwent elective coronary angioplasty with control and 5-minute balloon-occlusion ECG and sestamibi injection followed by single photon emission computed tomography (SPECT). The ST-vector direction derived from the inverse-Dower method was projected to an LV model with normal coronary artery anatomy. The graphical display of ST-vector location could discriminate among occlusions of the different coronaries. The ST-vector located ischemia within the SPECT defect in 75% (24/32) of all patients and 96% (24/25) of patients with ischemia in more than 12% of the LV. ST-vector magnitude had a Spearman correlation of r = 0.68 (P < .0001) with SPECT ischemia size.

Conclusions

The 3-dimensional ST vector derived from the ECG can be graphically projected onto an LV model to localize ischemia, and ST-vector magnitude correlates with ischemia size. Further study is warranted to assess the ability of vectorcardiographic imaging to risk-stratify and provide decision-support for patients with acute myocardial infarction.     

Electrocardiographic diagnosis of atrial infarction in patients with acute inferior ST‐segment elevation myocardial infarction

Background

Patients with atrial myocardial infarction (ATMI) have frequent cardiac and noncardiac complications. However, ATMI is uncommonly diagnosed because of its nonspecific ECG changes. Our objective was to analyze the ECG characteristics of ATMI in patients with inferior STEMI.

Hypothesis

Electrocardiographic P wave parameters can help in diagnosis of ATMI.

Methods

We evaluated 932 patients who underwent coronary angiography and recruited 39 patients with ATMI and 33 patients without ATMI with inferior STEMI for a retrospective study. Twelve‐lead ECGs were obtained to measure P‐wave parameters in diagnosis of ATMI. P‐wave parameters and PR‐segment displacement were compared in patients with and without ATMI.

Results

In inferior leads, PWD and PWDisp were significantly longer in the ATMI group than in the non‐ATMI group (limb lead II, 109.79 ±15.51 ms and 86.65 ±5.02 ms, respectively; P < 0.001; limb lead III, 108.31 ±12.51 ms and 85.27 ±7.47 ms, P < 0.001; aVF, 106.49 ±13.68 ms and 83.01 ±7.89 ms, P < 0.001; PWDisp, 41.67 ±10.72 ms and 25.18 ±5.17 ms, P < 0.001). By contrast, PWA was significantly lower in the ATMI group than in the non‐ATMI group (limb lead II, 0.96 ±0.18 mV and 1.39 ±0.22 mV, respectively; P < 0.001; limb lead III, 0.90 ±0.11 and 1.21 ±0.23, P < 0.001; aVF, 0.88 ±0.17 and 1.26 ±0.28, P < 0.001). PR‐segment displacement was found in 8 (20.5%) patients with ATMI. A PWD ≥95.5 ms in lead DII diagnosed ATMI with a higher sensitivity and specificity (90%, 94%) than did PWA or PWDisp.

Conclusions

This study suggests P‐wave parameters might be considered ECG findings in diagnosis of ATMI in patients with inferior STEMI.     

Intermittent fasting in Type 2 diabetes mellitus and the risk of hypoglycaemia: a randomized controlled trial

Aims

To establish whether the risk of hypoglycaemia is greater with 2 consecutive days of very‐low‐calorie diet compared with 2 non‐consecutive days of very‐low‐calorie diet in people with Type 2 diabetes.

Methods

This was a non‐blinded randomized parallel group interventional trial of intermittent fasting in adults. The participants had a BMI of 30–45 kg/m², Type 2 diabetes treated with metformin and/or hypoglycaemic medications and an HbA_1c concentration of 50–86 mmol/mol (6.7–10%). The participants followed a 2092–2510‐kJ diet on 2 days per week for 12 weeks. A total of 41 participants were randomized 1:1 to consecutive (n=19) or non‐consecutive (n=22) day fasts, of whom 37 (n=18 and n=19, respectively) were included in the final analysis. The primary outcome was difference in the rate of hypoglycaemia between the two study arms. Secondary outcomes included change in diet, quality of life, weight, lipid, glucose and HbA_1c levels, and liver function.

Results

The mean hypoglycaemia rate was 1.4 events over 12 weeks. Fasting increased the rate of hypoglycaemia despite medication reduction (RR 2.05, 95% CI 1.17 to 3.52). There was no difference between fasting on consecutive days and fasting on non‐consecutive days (RR 1.54, 95% CI 0.35 to 6.11). Improvements in weight, HbA_1c, fasting glucose and quality of life were experienced by participants in both arms.

Conclusions

In individuals with Type 2 diabetes on hypoglycaemic medications, fasting of any type increased the rate of hypoglycaemia. With education and medication reduction, fewer than expected hypoglycaemic events occurred. Although it was not possible to determine whether fasting on consecutive days increased the risk of hypoglycaemia, an acceptable rate was observed in both arms.     

Diagnostic value of the cardiac electrical biomarker,a novel ECG marker indicating myocardial injury,in patients with symptoms suggestive of non‐ST‐elevation myocardial infarction

Background

The cardiac electrical biomarker (CEB) is a novel electrocardiographic (ECG) marker quantifying the dipolar activity of the heart with higher levels indicating myocardial injury.

Methods

We prospectively enrolled 1097 patients presenting with suspected non‐ST‐elevation myocardial infarction (NSTEMI) to the emergency department (ED). Digital 12‐lead ECGs were recorded at presentation and the CEB values were calculated in a blinded fashion. The final diagnosis was adjudicated by two independent cardiologists. The prognostic endpoint was all‐cause mortality during 2 years of follow‐up.

Results

NSTEMI was the final diagnosis in 14% of patients. CEB levels were higher in patients with NSTEMI compared to other causes of chest pain (median 44 (IQR 21–98) vs. 30 (IQR 16–61), p < .001). A weak but significant correlation between levels of high‐sensitivity cardiac troponin T (hs‐cTnT) at admission to the ED and the CEB was found (r = .23, p < .001). The use of the CEB in addition to conventional ECG criteria improved the diagnostic accuracy for the diagnosis of NSTEMI as quantified by the area under the receiver operating characteristics curve from 0.66 to 0.71 (p < .001) and the sensitivity improved from 43% to 79% (p < .001).

Conclusion

In conclusion, the CEB, an ECG marker of myocardial injury, significantly improves the accuracy and sensitivity of the ECG for the diagnosis of NSTEMI.

     

Myocardial performance index suggests optimal fluid loss during hemodialysis

Background

Patients on long‐term maintenance hemodialysis (HD) are at high risk of developing cardiovascular disease and suffering various cardiovascular complications during HD.

Hypothesis

The purpose of this study was to evaluate the influence of changing loading conditions on the myocardial performance index (MPI) in patients on long‐term HD and to specify an optimal level of fluid loss during HD that would maintain stable global cardiac function.

Methods

The study consisted of 52 patients with end‐stage renal failure (ESRF), mean age 56±11.7 y, range: 25–80 y, on regular HD. For each patient a complete echocardiographic‐Doppler examination was performed before and after HD. Systolic and diastolic parameters of left ventricular function were measured, and the myocardial performance index (MPI) was calculated.

Results

The MPI was significantly prolonged after HD (0.47±0.15 before HD versus 0.59±0.16 after HD, p < 0.001). Mean change in body weight during HD was 2.1±0.86 kg. The MPI did not change significantly in patients with intradialytic weight loss up to 1.75 kg.

Conclusions

The MPI value seems to be independent of acute preload changes only when fluid loss is less than 1.75 kg. A 1.75‐kg fluid loss during HD seems to be the optimal goal. In ESRF patients on HD, the MPI seems to be a good indicator of global left ventricular function and potentially a valuable aid in the effort to maintain optimal fluid balance. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

Usefulness of tissue Doppler imaging-myocardial performance index in the evaluation of diastolic dysfunction and heart failure with preserved ejection fraction

Background:

In heart failure with preserved ejection fraction (HFPEF), physiological abnormalities are not solely restricted to diastolic function. Because the tissue Doppler imaging (TDI)‐derived myocardial performance index (MPI) offers the advantage of recording systolic and diastolic tissue velocity simultaneously in the same cardiac cycle, this study aimed to determine whether TDI‐MPI is an informative index for assessing HFPEF, compared with conventional echo parameters.

Hypothesis:

In patients with HFPEF, TDI‐MPI would be an independent predictor for adverse cardiac events.

Methods:

Among 408 patients who had diastolic dysfunction without heart failure (HF) or HFPEF, cardiac function was evaluated by mitral flow (MF) or TDI‐MPI. During the median follow‐up of 32 months, clinical outcomes, which were defined as the composite of cardiovascular death and admission for HF, were assessed.

Results:

Mean MF and TDI‐MPI were significantly greater in the HFPEF group. TDI‐MPI rather than MF had a significant correlation with N‐terminal pro‐brain natriuretic peptide level. The area under the receiver operating characteristic curve of TDI‐MPI for the detection of HFPEF was 0.86. With regard to clinical outcomes, 31 events were identified during follow‐up periods. On a multivariate analysis, TDI‐MPI >0.66 was the best prognostic predictor of events and provided incremental predictive value.

Conclusions:

Compared to MF‐MPI, TDI‐MPI may be a more useful parameter for the evaluation of patients with HFPEF. © 2011 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

Outcomes by Day and Night for Patients Bypassing the Emergency Department Presenting with ST‐Segment Elevation Myocardial Infarction Identified with a Pre‐Hospital Electrocardiogram

Background

Pre‐hospital ECG and emergency department (ED) bypass direct to the catheter laboratory may optimize reperfusion times for patients with ST‐segment elevation myocardial infarction. Questions remain over feasibility and safety during off hours.

Aims

To determine if presenting time of day is associated with differences in in‐hospital and 30‐day mortality and key reperfusion times.

Methods/Results

Seven hundred and twenty consecutive patients with STEMI triaged directly from the field to the catheter laboratory between June 2004–May 2013. Vital status was reported as of August 2013. The mean age was 65 ± 14 years, and 75.1% were male. Overall mortality (in‐hospital/30 days) did not significantly differ for patients (3.4% in hours and 3.1% off hours; P = N/S). Symptom onset‐to‐arrival to the heart attack was non‐significantly lower (100 minutes off hours (IQR 78–174) versus 110 minutes in hours (IQR 75–199), P = N/S). Call‐to‐balloon time was not significantly affected by the time of presentation: 150 min in hours (IQR 111–239) versus 154 minutes during off hours (IQR 115–225) P = N/S. Overall door‐to‐balloon time was 36 minutes (IQR 25–51), 34 minutes in hours (IQR 24–49) versus 40 minutes off hours (IQR 29–55) P = N/S. The overall false positive activation rate was only 13.1%, (in hours 12.2% vs. off hours 14.6%, respectively, P = N/S).

Conclusions

In a unit with an established field triage system facilitating ED bypass, reperfusion times and mortality are not significantly influenced by whether the patient presents during standard working hours or outside of these hours. (J Interven Cardiol 2015;28:24–31)

     

Discrepancy between stress electrocardiographic changes and nuclear myocardial perfusion defects in the prognostic assessment of patients with chest pain

ObjectivesThe aim of the present study was to determine the long-term prognostic value provided by the exercise electrocardiographic (ECG) response to nuclear myocardial perfusion imaging (MPI) in the evaluation of patients with chest pain, focusing on patients with a discrepancy between the two tests.MethodsA total of 1460 consecutive patients (777 female; 62.6±11.4 years) undergoing exercise myocardial single-photon emission computed tomography (SPECT) were included. The endpoint was the occurrence of acute coronary syndrome, heart failure or cardiac death during follow-up.ResultsIschemic ECG changes were observed during stress testing in 271 patients (18.5%) and 362 patients (24.7%) had positive (abnormal) exercise MPI results. There was a discrepancy between ECG and SPECT findings in 471 patients (32.2%). During the follow-up period (14.0-39.6 months), 224 patients (15.3%) presented cardiac events. The hazard ratios (HR) of ECG and MPI results to predict events were 1.506 (95% CI: 1.113-2.039) and 10.481 (95% CI: 7.799-14.080), respectively. In patients with negative MPI, the ECG response did not predict events (HR 1.214 [95% CI: 0.646-2.282]), the same as in patients with positive MPI (HR 1.203 [95% CI: 0.848-1.705]). Only in hypertensive patients with positive SPECT did the ECG show significant prognostic value (HR 1.937 [95% CI: 1.030-3.642]). In multivariate analysis, positive MPI proved an independent long-term prognostic factor (HR 10.536 [95% CI: 7.759-14.308]), but not ECG (HR 1.356 [95% CI: 0.994-1.850]).ConclusionMPI results (normal vs. abnormal) had strong predictive value and discrepant ECG results had no significant additive prognostic value.     

Characteristics of Rural Crack and Powder Cocaine Use: Gender and Other Correlates

Background: Little is known about the relationship of gender with cocaine use in rural areas. This study describes these relationships among stimulant users residing in rural areas of Arkansas, Kentucky, and Ohio. Objectives: Understanding the characteristics of crack and powder cocaine users in rural areas may help inform prevention, education, and treatment efforts to address rural stimulant use. Methods: Participants were 690 stimulant users, including 274 (38.6%) females, residing in nine rural counties. Cocaine use was measured by self-report of cocaine use, frequency of use, age of first use, and cocaine abuse/dependence. Powder cocaine use was reported by 49% of this sample of stimulant users and 59% reported using crack cocaine. Findings: Differing use patterns emerged for female and male cocaine users in this rural sample; females began using alcohol, marijuana, and cocaine at later ages than males but there were no gender differences in current powder cocaine use. Females reported more frequent use of crack cocaine and more cocaine abuse/dependence than males, and in regression analyses, female crack cocaine users had 1.8 times greater odds of reporting frequent crack use than male crack users. Conclusions and Scientific Significance: These findings suggest differing profiles and patterns of cocaine use for male and female users in rural areas, supporting previous findings in urban areas of gender-based vulnerability to negative consequences of cocaine use. Further research on cocaine use in rural areas can provide insights into gender differences that can inform development and refinement of effective interventions in rural communities.     

Cutaneous vasculopathy associated with cocaine use

Objective

Cocaine is known to cause thrombotic complications. Its use has also been associated with a variety of rheumatologic manifestations, most notably cutaneous vasculopathy. We report clinical features and laboratory findings of cocaine‐related cutaneous vasculopathy.

Methods

Here we describe 8 patients with cocaine‐related cutaneous vasculopathy.

Results

Our patients most commonly presented with purpuric lesions and ulcers with areas of skin necrosis. Extracutaneous features included fatigue and arthritis in most patients, as well as weight loss in 3 patients, pneumonia in 3, diffuse reactive lymphadenopathy in 1, and acute upper airway obstruction in 2. Laboratory abnormalities included elevated inflammatory markers and positive perinuclear antineutrophil cytoplasmic antibodies (ANCAs) in all patients, and antimyeloperoxidase antibodies in 7 of 8 patients. Cytoplasmic ANCA was positive in 5 of 8, equivocal in 2 of 8, and negative in 1 of 8 patients. Anti–proteinase 3 antibodies were found in 6 of 8 patients. Six of 8 patients had positive antinuclear antibodies and 5 of 8 had positive anti–double‐stranded DNA antibodies (4 of 5 were at low titers). Two patients previously thought to have systemic lupus erythematosus had low complement levels. Lupus anticoagulant was positive in 3 of 8 and equivocal in 5 of 8. Anticardiolipin IgG was positive in 1 of 8 and IgM was positive in 6 of 8; β₂‐glycoprotein I IgM was positive in 2 of 8. Cold agglutinins were strongly positive in 6 of 6 patients in whom they were measured. Skin disease improved in 3 patients who appeared to have stopped using cocaine. It was chronic and progressive in 4 patients who continued to use cocaine, 2 of whom died presumably due to multidrug overdose.

Conclusion

This report outlines clinical features and distinctive laboratory findings that, when present in the right clinical setting, should prompt consideration of cocaine‐related cutaneous vasculopathy.