Top Things to Know: Management of Cocaine-Associated Chest Pain and Myocardial Infarction
Published: March 17, 2008
- In the last 6 months of 2004 there were ~ 126,000 cocaine-related Emergency Department in the United States.
- 37% of cocaine-related Emergency Department visits involve individuals 35 to 44 years of age; younger patients or those with few cardiac risk factors with ACS should be questioned about cocaine use.
- The most frequently reported symptoms are Chest pain, dyspnea, diaphoresis, palpitations, dizziness, and nausea.
- Cocaine-associated myocardial infarction occurs after cocaine ingestion in 0.7% to 6% of individuals.
- Patients with non-diagnostic ECG findings and normal cardiac markers should be managed in a chest pain observation unit for 9-12 hours; stress testing may be considered based on other risk factors and clinical status.
- Cocaine-associated ACS should be treated like spontaneous ACS with the following exceptions (Class/level of evidence):
- Benzodiazepines (I/B): neuropsychiatric effects can relieve chest pain and lead to beneficial hemodynamic effects.
- β-blockers, including labetalol (III/C) should be avoided in the acute setting due to unopposed α-adrenergic effects, which may lead to worsening coronary vasoconstriction and increased blood pressure.
- Calcium channel blockers (IIb/C) should not be used as first-line therapy but may be considered in patients not responsive to benzodiazepines or nitroglycerin.
- Phentolamine (IIb/C): phentolamine decreases coronary vascular resistance and blood pressure after cocaine ingestion, and may be considered in patients not responsive to nitroglycerin or calcium channel blockers.
- Patients with evidence of MI or atherosclerosis should receive long term antiplatelet therapy with aspirin.
- Long-term β-blocker therapy should be considered in those with documented myocardial infarction, decreased left ventricular systolic function, or ventricular arrhythmias who are at low risk for recurrent use of cocaine.
- Cessation of cocaine should be the primary goal of secondary prevention.
- Recurrent chest pain is less common and MI and death are rare in patients who discontinue cocaine.
Citation
McCord J, Jneid H, Hollander JE, et al. Management of cocaine-associated chest pain and myocardial infarction: a scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Circulation. 2008;117(14):1897-1907. doi:10.1161/CIRCULATIONAHA.107.188950