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Three Part Question

In [a cocaine user presenting to an Emergency Department with chest pain] are [nitrates superior to benzodiazepines] at [resolving chest pain]

Clinical Scenario

A 21 year old man attends the emergency department complaining of cardiac sounding chest pain. He has no risk factors for ischaemic heart disease but admits to recent cocaine abuse. His ECG reveals appears ischaemic. You wonder if nitrates or benzodiazepines, in combination or alone, compare at resolving chest pain and clinical outcome.

Search Strategy

Medline 1966 to February 2006 using the OVID interface:
[{exp cocaine OR cocaine-related disorders.mp.} AND {exp chest pain OR ischaemia OR angina OR acute coronary syndrome OR infarction.mp.} AND {exp diazepam OR exp benzodiazepines OR nitrates.mp.}].

Search Outcome

7 papers found of which 2 were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Baumann et al, 2000, USA	44 patients attending ED all took cocaine within 24 hours (median 5 hrs 37 mins) with history suggestive of ischaemic chest pain age 18-60 years	Randomised control double blind placebo control	Pain score, chest pain severity	No difference between either agent alone or in combination in terms of score reduction	Possibility of concomitant coronary artery disease, Anxieties regarding perception symptomatology by cocaine users Possibility of non ischaemic chest pain
			Haemodynamic performance and Cardiac performance	When baseline differences adjusted statistical comparisons showed no demonstrable difference
Honderick et al, 2003, USA	27 patients attending ED chest pain < 72 h duration 15 treated NTG alone 12 treated NTG and lorazepam. NTG group then crossed over	Randomised prospective single blind control	Pain score chest pain severity	Mean pain score at 5 mins 1.24 lower in NTG and Lorazepam group(p <0.02)	Convenience sample Sample size small No placebo arm for iv lorazepam Unusual therapeutic regimen No follow up

Comment(s)

The demographics of both of the study populations are comparable to that of cocaine users that attend the emergency department. The presenting electrocardiograms were largely normal in these patients. Treatment was based largely on history and symptoms. Nitrates were used sublingually. Diazepam was administered intravenously. Very small numbers and lack of a placebo for lorazepam in the second paper may be responsible for the reduction in pain scores seen when patients who received both agents

Clinical Bottom Line

In patients with cocaine induced chest pain it appears that nitrates or benzodiazepines alone are effective in combination or alone in resolving chest pain and improving cardiac performance. Authors recommend that the agent of choice may be influenced by the prescence or abscence of concurrent CNS symptoms.

References

1. Baumann BM. Perrone J. Hornig SE et al. Randomized, double-blind, placebo-controlled trial of diazepam, nitroglycerin, or both for treatment of patients with potential cocaine-associated acute coronary syndromes. Academic Emergency Medicine 2000 Vol 7(8);878-885.
2. Honderick T. Williams D. Seaberg D et al. A prospective, randomized, controlled trial of benzodiazepines and nitroglycerine or nitroglycerine alone in the treatment of cocaine -associated acute coronary syndromes. American Journal of Emergency Medicine 2003;21(1):39-42.