The implications of cocaine use and associated behaviors on adverse cardiovascular outcomes among veterans: Insights from the VA Clinical Assessment, Reporting, and Tracking (CART) Program

Background: Cocaine use has been associated with adverse cardiovascular outcomes in patients with coronary artery disease (CAD). It is unclear whether this is due to direct effects of cocaine or other factors. Hypothesis: Cocaine use is associated with worse outcomes in patients undergoing cardiac catheterization. Methods: We used the Veterans Affairs database to identify veterans undergoing coronary catheterization between 2007 and 2014. We analyzed association between cocaine use and 1-year all-cause mortality, myocardial infarction (MI), and cerebrovascular accident (CVA) among veterans with obstructive CAD (N = 122 035). To explore factors contributing to these associations, we sequentially adjusted for cardiac risk factors, risky behaviors, and clinical conditions directly affected by cocaine. Results: 3082 (2.5%) veterans were cocaine users. Cocaine users were younger (median 58.2 vs 65.3 years; P < 0.001), more likely to be African American (58.9% vs 10.6%; P < 0.001), and had fewer traditional cardiac risk factors. After adjustment for cardiac risk factors, cocaine was associated with increased risk of mortality (HR: 1.23, 95% CI: 1.08-1.39), MI (HR: 1.40, 95% CI: 1.07-1.83), and CVA (HR: 1.88, 95% CI: 1.38-2.57). With continued adjustment, increased CVA risk remained significantly associated with cocaine use, whereas MI risk was mediated by risky behaviors and mortality was fully explained by conditions directly affected by cocaine. Conclusions: Cocaine use is associated with adverse cardiac events in veterans with CAD. Contributors to this association are multifaceted and specific to individual cardiovascular outcomes, including associated risky behaviors and direct effects of cocaine. Effective intervention programs to reduce cardiac events in this population will require multiple components addressing these factors.