Cocaine induced myocardial ischaemia: nitrates versus benzodiazepines

Cocaine abuse: acute medical manifestations & current recommended management strategies

“…The most comprehensive guidance comes from the American College of Cardiology/American Heart Association (ACC/AHA). 14 Sublingual or intravenous (IV) nitrates and oral or IV calcium channel blockers are recommended (Class I) for patients with ST segment abnormalities in association with ischaemic chest pain. Sublingual nitrates and oral calcium channel blockers are recommended (Class IIa) for patients whose ECG is normal or shows only minor abnormalities, with a history suggestive of ischaemic pain.…”

“…17 Although drugs like labetolol show no reduction in coronary vasoconstriction, the ACC/AHA does not completely exclude the use of combined ␣ and ␤-blockers but recommends that they are used only after standard vasodilator therapy and only in patients with systemic hypertension and sinus tachycardia. 14,18 Use of a centrally acting ␣-adrenergic receptor blocker (e.g. dexmedetomidine) to counteract central sympathetic activity has been proposed, however data is insufficient for this to be recommended at present.…”

“…The use of thrombolytic agents is contra-indicated unless ST segment elevation persists and angiography is not available. 14…”

“…22 Coronary angiography is recommended for patients with ST-segment depression or isolated T-wave inversion following cocaine-associated chest pain but there is no specific guidance for cases where the troponin is positive with a normal ECG. 14 It is therefore recommended that this particular subset of patients is referred to a cardiologist once biochemical markers are available to assist with further management and investigation.…”

Toxicologic issues during cardiopulmonary resuscitation

“…No benefit of one agent over the other is clear [60 ]. Although ß-blockers are considered standard therapy in acute coronary syndromes, there is good evidence to show that ß-blockers such as propranolol can worsen myocardial vasoconstriction in the setting of cocaine use [61].…”