Rethinking Cocaine-Associated Chest Pain and Acute Coronary Syndromes

Abstract

Every year more than 500,000 patients present to the emergency department with cocaine-associated complications, most commonly chest pain. Many of these patients undergo extensive work-up and treatment. Much of the evidence regarding cocaine's cardiovascular effects, as well as the current management of cocaine-associated chest pain and acute coronary syndromes, is anecdotally derived and based on studies written more than 2 decades ago that involved only a few patients. Newer studies have brought into question many of the commonly held theories and practices regarding the etiology, diagnosis, and treatment of this common clinical scenario. However, there continues to be a paucity of prospective, randomized trials addressing this topic as it relates to clinical outcomes. We searched PubMed for Englishlanguage articles from 1960 to 2011 using the keywords cocaine, chest pain, coronary arteries, myocardial infarction, emergency department, cardiac biomarkers, electrocardiogram, coronary computed tomography, observation unit, β-blockers, benzodiazepines, nitroglycerin, calcium channel blockers, phentolamine, and cardiomyopathy; including various combinations of these terms. We reviewed the abstracts to confirm relevance, and then full articles were extracted. References from extracted articles were also reviewed for relevant articles. In this review, we critically evaluate the limited historical evidence underlying the current teachings on cocaine's cardiovascular effects and management of cocaine-associated chest pain. We aim to update the reader on more recent, albeit small, studies on the emergency department evaluation and clinical and pharmacologic management of cocaine-associated chest pain. Finally, we summarize recent guidelines and review an algorithm based on the current best evidence. Proc. 2011;86(12):1198-1207 ACS = acute coronary syndrome; AHA = American Heart Association; CCB = calcium channel blockers; CCP = cocaine-associated chest pain; DBP = diastolic blood pressure; ECG = electrocardiography; ED = emergency department; HR = heart rate; MAP = mean arterial pressure; MI = myocardial infarction; PCI = percutaneous coronary intervention; SBP = systolic blood pressure; STEMI = ST-segment elevation myocardial infarction; TIMI = Thrombolysis in Myocardial Infarction E very year millions of Americans abuse cocaine, many of whom present to the emergency department (ED) with cocaine-related complications, most commonly chest pain. Unfortunately, much of the current thinking on cocaine and its cardiovascular effects is either anecdotally derived or based on small studies conducted more than 2 decades ago. Recently, newer studies have brought into question many of the commonly held theories and practices regarding the etiology, diagnosis, and management of cocaine-associated chest pain (CCP) and suspected myocardial ischemia. Mayo ClinWe searched PubMed for English-language articles from 1960 to 2011 using the keywords cocaine, chest pain, coronary arteries, myocardial infarction, emergency department, card...

Cocaine cardiomyopathy: A case report

“…Patients also may present with acute myocardial decompensation with or without pulmonary edema and shock. In this case, shortness of breath and hypoperfusion dominate the clinical picture (1,6,7,8).…”

“…Associations of cardiologists don't have recommendations for concrete medicamentous treatment of cocaine cardiomyopathy (1). Management of these patients is similar to that of patients with other forms of dilated cardiomyopathy, although beta-blockers should be included in patients with cocaine-associated heart failure and benzodiazepines should be given in this setting to blunt adrenergic excess.…”

“…In a retrospective of European study of 479 ACS patients younger than 50 years admitted to a critical care unit from 2001 to 2008, a total of 24 patients (5%) had admitted to recent cocaine abuse or tested positive on urine drug screening (1). In 2005, 2.4 million persons were actively using cocaine.…”

“…The sympathomimetic actions of cocaine, at cellular level, are mediated by stimulation of the a and b adrenergic receptors. Cocaine also interacts with the muscarinic receptors, and inhibits the reuptake of dopamine and seretonin by nerve endings (1).…”

Cocaine use does not affect mean platelet volume

“…Cocaine, one of the most commonly used illicit drugs in United States, is associated with a wide spectrum of cardiovascular complications including myocardial infarction fi rst reported in 1982 [2]. Every year, more than 500,000 patients present to hospital emergency department with cocaine-associated cardiovascular complications, most commonly chest pain [3]. Many cases of myocardial infarction have been reported in cocaine users who have normal coronaries [4].…”