CTA and Cocaine‐associated Chest Pain: More Evidence Is Needed

The recent study utilizing computed tomographic angiography (CTA) to risk stratify low- to intermediate-risk patients with cocaine-associated chest pain posed an interesting clinical question.1 However, given the low incidence of myocardial infarction in patients with cocaine-related chest pain2 and their propensity for recurrent emergency department (ED) visits,3 we question whether CTA is indicated in this population. The utility of CTA in patients with low- to moderate-risk chest pain has not been fully established.4 Furthermore, the quality of the image relies on multiple factors, including heart rate and minimal presence of coronary calcium, as the presence of calcium creates interference. Additionally, the pharmacologic agents, such as beta-adrenergic antagonists, which are often required to achieve the target heart rate, may induce life-threatening vasoconstriction in patients with active cocaine use.5,6 Given the propensity for repeat ED visits, patients may incur a significant lifetime radiation exposure from repeat cardiac imaging7 from a disease with exceedingly low morbidity and mortality.8 We conclude that CTA is not an optimal diagnostic modality for assessment of coronary artery disease in patients with cocaine-associated chest pain. The patients were subjected to risks of beta-blockade and significant radiation exposure to undergo a diagnostic study that was not only unable to determine the presence of coronary disease and/or confirm its absence by the accepted criterion standard diagnostic modalities, but also unlikely to yield clinically useful information.