Cocaine-associated chest pain - Revision history

Kramarsh: /* Background */

2018-03-26T16:13:48Z

Background

← Older revision		Revision as of 16:13, 26 March 2018
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	*6% incidence of AMI with cocaine chest pain		*6% incidence of AMI with cocaine chest pain
	*Cocaine associated with 24x risk of true MI		*Cocaine associated with 24x risk of true MI
			*Be aware of cocaethylene metabolites in the setting of EtOH use, will produce longer symptoms and potentially be more directly cardiotoxic

	==Clinical Features==		==Clinical Features==

Neil.m.young: Text replacement - "alpha" to "α"

2017-07-24T01:13:19Z

Text replacement - "alpha" to "α"

← Older revision		Revision as of 01:13, 24 July 2017
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	*[[Benzos]] directed at symptom relief, not necessarily hypertension and tachycardia<ref name="McCord"></ref>		*[[Benzos]] directed at symptom relief, not necessarily hypertension and tachycardia<ref name="McCord"></ref>
	*Consider [[Nitroglycerin]], [[Nitroprusside]], [[Phentolamine]] (1mg IV), or [[Calcium channel blockers\|CCB]] (in benzodiazepine non-responders)		*Consider [[Nitroglycerin]], [[Nitroprusside]], [[Phentolamine]] (1mg IV), or [[Calcium channel blockers\|CCB]] (in benzodiazepine non-responders)
	*Avoid [[beta-blockers]] due to the possibility of unopposed ~~alpha~~ activity. Labetolol although offering the theoretical advantage of blocking both ~~alpha~~ and beta receptors does not reverse coronary artery vasoconstriction<ref>Boehrer JD. et al. Influence of labetalol on cocaine-induced coronary vasoconstriction in humans. Am J Med. 1993; 94: 608– 610</ref><ref> Lange RA. et al. Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade. Ann Intern Med. 1990; 112: 897–903</ref>		*Avoid [[beta-blockers]] due to the possibility of unopposed α activity. Labetolol although offering the theoretical advantage of blocking both α and beta receptors does not reverse coronary artery vasoconstriction<ref>Boehrer JD. et al. Influence of labetalol on cocaine-induced coronary vasoconstriction in humans. Am J Med. 1993; 94: 608– 610</ref><ref> Lange RA. et al. Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade. Ann Intern Med. 1990; 112: 897–903</ref>
	**Though not accepted in common practice, new evidence suggest no significant risk and a benefit to using beta blockade in these patients<ref>Dattilo PB et al. β-blockers are associated with reduced risk of myocardial infarction after cocaine use. Ann Emerg Med. 2008; 51:117.</ref><ref>Finkel JB and Marhefka GD. Rethinking cocaine-associated chest pain and acute coronary syndromes. Mayo Clin Proc. 2011; 86(12):1198-1207. </ref><ref> Rangel C, et al. Marcus GM. Beta-blockers for chest pain associated with recent cocaine use. Arch Intern Med. 2010; 170(10):874-879.</ref>		**Though not accepted in common practice, new evidence suggest no significant risk and a benefit to using beta blockade in these patients<ref>Dattilo PB et al. β-blockers are associated with reduced risk of myocardial infarction after cocaine use. Ann Emerg Med. 2008; 51:117.</ref><ref>Finkel JB and Marhefka GD. Rethinking cocaine-associated chest pain and acute coronary syndromes. Mayo Clin Proc. 2011; 86(12):1198-1207. </ref><ref> Rangel C, et al. Marcus GM. Beta-blockers for chest pain associated with recent cocaine use. Arch Intern Med. 2010; 170(10):874-879.</ref>
	*Consider [[NaHOC3]] for Ventricular Arrythmias immediately following cocaine use		*Consider [[NaHOC3]] for Ventricular Arrythmias immediately following cocaine use

Mholtz at 01:43, 10 May 2017

2017-05-10T01:43:34Z

← Older revision		Revision as of 01:43, 10 May 2017
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	==Background==		==Background==
	Cocaine ~~is a catalyst~~ for ~~CAD &~~ up to ~~6% of cocaine related chest pain develop an MI, however, a 9-12 hour period of ECG's~~ and serial troponins can be safe. Of the 334 patients studied, if both were negative, no deaths from cardiovascular events occurred at 30 days. 4 patients did have non-fatal MI's but were using coc at the time.<ref>~~Kloner RA and Rezkalla SH~~. ~~Cocaine~~ and ~~the heart~~. ~~N Engl J Med~~. ~~2003~~; ~~348~~:~~487~~-~~488~~.</ref>		*Cocaine causes vasoconstriction, which can precipitate MI
			**Cocaine metabolites can persist for up to 24hrs and cause delayed or recurrent coronary vasoconstriction<ref name="McCord">McCord J, et al. Management of cocaine-associated chest pain and myocardial Infarction. Circulation. 2008; 117:1897-1907.</ref>
	~~===Epidemiology===~~
	*Causes vasculitis
	*6% incidence of AMI with cocaine chest pain		*6% incidence of AMI with cocaine chest pain
	*Cocaine associated with 24x risk of true MI		*Cocaine associated with 24x risk of true MI
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	==Clinical Features==		==Clinical Features==
	*[[Chest pain]] in the setting of cocaine or related stimulant use		*[[Chest pain]] in the setting of cocaine or related stimulant use
	*Cocaine metabolites can persist for up to 24hrs and cause delayed or recurrent coronary vasoconstriction<ref name="McCord">McCord J, et al. Management of cocaine-associated chest pain and myocardial Infarction. Circulation. 2008; 117:1897-1907.</ref>

	==Differential Diagnosis==		==Differential Diagnosis==
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	==Disposition==		==Disposition==
	*~~May~~ discharge after: 9-12 hour ~~period of ECG's~~ and serial ~~troponins, if both are negative~~		*Consider discharge after 9-12 hour observation if pain free, no EKG changes and negative serial troponin
	**In NEJM ~~2/03; n=~~334~~; outcome of zero~~ events at ~~30dys if no more~~ cocaine		**In NEJM study, 334 patients studied. If both EKG and troponins negative, no deaths from cardiovascular events at 30 days. 4 patients did have non-fatal MI's but were using cocaine at the time.<ref>Kloner RA and Rezkalla SH. Cocaine and the heart. N Engl J Med. 2003; 348:487-488.</ref>
			*Otherwise admit
	~~===Consider Admission===~~
	*~~Persistent chest pain~~
	*[[ECG]] changes
	*[[Arrhythmia]]
	*[[CHF]]
	*Elevated [[troponin]]

	==See Also==		==See Also==
	*[[Cocaine]]		*[[Cocaine]]
	*[[Cocaine toxicity]]		*[[Cocaine toxicity]]
	*[[Cocaine ~~Withdrawal~~]]		*[[Cocaine withdrawal]]
	*[[Acute Coronary Syndrome (Main)]]		*[[Acute Coronary Syndrome (Main)]]

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	<references/>		<references/>

	[[Category:Cardiology]] [[Category:Toxicology]]		[[Category:Cardiology]]
			[[Category:Toxicology]]

Lisayee25: /* Management */

2017-05-06T02:44:31Z

Management

← Older revision		Revision as of 02:44, 6 May 2017
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	*[[ASA]]		*[[ASA]]
	*[[Benzos]] directed at symptom relief, not necessarily hypertension and tachycardia<ref name="McCord"></ref>		*[[Benzos]] directed at symptom relief, not necessarily hypertension and tachycardia<ref name="McCord"></ref>
	*Consider [[Nitroglycerin]], [[Nitroprusside]], [[Phentolamine]] (1mg IV), or [[CCB] (in benzodiazepine non-responders)		*Consider [[Nitroglycerin]], [[Nitroprusside]], [[Phentolamine]] (1mg IV), or [[Calcium channel blockers\|CCB]] (in benzodiazepine non-responders)
	*Avoid [[beta-blockers]] due to the possibility of unopposed alpha activity. Labetolol although offering the theoretical advantage of blocking both alpha and beta receptors does not reverse coronary artery vasoconstriction<ref>Boehrer JD. et al. Influence of labetalol on cocaine-induced coronary vasoconstriction in humans. Am J Med. 1993; 94: 608– 610</ref><ref> Lange RA. et al. Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade. Ann Intern Med. 1990; 112: 897–903</ref>		*Avoid [[beta-blockers]] due to the possibility of unopposed alpha activity. Labetolol although offering the theoretical advantage of blocking both alpha and beta receptors does not reverse coronary artery vasoconstriction<ref>Boehrer JD. et al. Influence of labetalol on cocaine-induced coronary vasoconstriction in humans. Am J Med. 1993; 94: 608– 610</ref><ref> Lange RA. et al. Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade. Ann Intern Med. 1990; 112: 897–903</ref>
	**Though not accepted in common practice, new evidence suggest no significant risk and a benefit to using beta blockade in these patients<ref>Dattilo PB et al. β-blockers are associated with reduced risk of myocardial infarction after cocaine use. Ann Emerg Med. 2008; 51:117.</ref><ref>Finkel JB and Marhefka GD. Rethinking cocaine-associated chest pain and acute coronary syndromes. Mayo Clin Proc. 2011; 86(12):1198-1207. </ref><ref> Rangel C, et al. Marcus GM. Beta-blockers for chest pain associated with recent cocaine use. Arch Intern Med. 2010; 170(10):874-879.</ref>		**Though not accepted in common practice, new evidence suggest no significant risk and a benefit to using beta blockade in these patients<ref>Dattilo PB et al. β-blockers are associated with reduced risk of myocardial infarction after cocaine use. Ann Emerg Med. 2008; 51:117.</ref><ref>Finkel JB and Marhefka GD. Rethinking cocaine-associated chest pain and acute coronary syndromes. Mayo Clin Proc. 2011; 86(12):1198-1207. </ref><ref> Rangel C, et al. Marcus GM. Beta-blockers for chest pain associated with recent cocaine use. Arch Intern Med. 2010; 170(10):874-879.</ref>

Alvarez13: /* Evaluation */

2017-03-20T00:46:06Z

Evaluation

← Older revision		Revision as of 00:46, 20 March 2017
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	*1-3hrs onset from last use		*1-3hrs onset from last use
	**If >3 hrs = lower risk of [[AMI]]		**If >3 hrs = lower risk of [[AMI]]
	*Most with characteristic pain		*Most with characteristic pain
	*Dyspnea, diaploresis, and nausea		**Dyspnea, diaploresis, and nausea
	*Most have normal vitals		*Most have normal vitals
			*ECG

	==Management==		==Management==

Rossdonaldson1: /* Management */

2017-02-18T21:41:04Z

Management

← Older revision		Revision as of 21:41, 18 February 2017
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	*[[ASA]]		*[[ASA]]
	*[[Benzos]] directed at symptom relief, not necessarily hypertension and tachycardia<ref name="McCord"></ref>		*[[Benzos]] directed at symptom relief, not necessarily hypertension and tachycardia<ref name="McCord"></ref>
	*Consider [[~~NTG~~]], [[Nitroprusside]], [[Phentolamine]] (1mg IV), or [[CCB] (in benzodiazepine non-responders)		*Consider [[Nitroglycerin]], [[Nitroprusside]], [[Phentolamine]] (1mg IV), or [[CCB] (in benzodiazepine non-responders)
	*Avoid [[beta-blockers]] due to the possibility of unopposed alpha activity. Labetolol although offering the theoretical advantage of blocking both alpha and beta receptors does not reverse coronary artery vasoconstriction<ref>Boehrer JD. et al. Influence of labetalol on cocaine-induced coronary vasoconstriction in humans. Am J Med. 1993; 94: 608– 610</ref><ref> Lange RA. et al. Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade. Ann Intern Med. 1990; 112: 897–903</ref>		*Avoid [[beta-blockers]] due to the possibility of unopposed alpha activity. Labetolol although offering the theoretical advantage of blocking both alpha and beta receptors does not reverse coronary artery vasoconstriction<ref>Boehrer JD. et al. Influence of labetalol on cocaine-induced coronary vasoconstriction in humans. Am J Med. 1993; 94: 608– 610</ref><ref> Lange RA. et al. Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade. Ann Intern Med. 1990; 112: 897–903</ref>
	**Though not accepted in common practice, new evidence suggest no significant risk and a benefit to using beta blockade in these patients<ref>Dattilo PB et al. β-blockers are associated with reduced risk of myocardial infarction after cocaine use. Ann Emerg Med. 2008; 51:117.</ref><ref>Finkel JB and Marhefka GD. Rethinking cocaine-associated chest pain and acute coronary syndromes. Mayo Clin Proc. 2011; 86(12):1198-1207. </ref><ref> Rangel C, et al. Marcus GM. Beta-blockers for chest pain associated with recent cocaine use. Arch Intern Med. 2010; 170(10):874-879.</ref>		**Though not accepted in common practice, new evidence suggest no significant risk and a benefit to using beta blockade in these patients<ref>Dattilo PB et al. β-blockers are associated with reduced risk of myocardial infarction after cocaine use. Ann Emerg Med. 2008; 51:117.</ref><ref>Finkel JB and Marhefka GD. Rethinking cocaine-associated chest pain and acute coronary syndromes. Mayo Clin Proc. 2011; 86(12):1198-1207. </ref><ref> Rangel C, et al. Marcus GM. Beta-blockers for chest pain associated with recent cocaine use. Arch Intern Med. 2010; 170(10):874-879.</ref>

Rossdonaldson1: /* Management */

2017-02-18T21:40:42Z

Management

← Older revision		Revision as of 21:40, 18 February 2017
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	==Management==		==Management==
	*ASA~~, NTG, O2~~		*[[ASA]]
	*Benzos directed at symptom relief, not necessarily hypertension and tachycardia<ref name="McCord"></ref>		*[[Benzos]] directed at symptom relief, not necessarily hypertension and tachycardia<ref name="McCord"></ref>
	*Consider NTG, Nitroprusside, Phentolamine (1mg IV), or CCB (in ~~benzodiazepinenon~~ responders)		*Consider [[NTG]], [[Nitroprusside]], [[Phentolamine]] (1mg IV), or [[CCB] (in benzodiazepine non-responders)
	*Avoid beta blockers due to the possibility of unopposed alpha activity. Labetolol although offering the theoretical advantage of blocking both alpha and beta receptors does not reverse coronary artery vasoconstriction<ref>Boehrer JD. et al. Influence of labetalol on cocaine-induced coronary vasoconstriction in humans. Am J Med. 1993; 94: 608– 610</ref><ref> Lange RA. et al. Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade. Ann Intern Med. 1990; 112: 897–903</ref>		*Avoid [[beta-blockers]] due to the possibility of unopposed alpha activity. Labetolol although offering the theoretical advantage of blocking both alpha and beta receptors does not reverse coronary artery vasoconstriction<ref>Boehrer JD. et al. Influence of labetalol on cocaine-induced coronary vasoconstriction in humans. Am J Med. 1993; 94: 608– 610</ref><ref> Lange RA. et al. Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade. Ann Intern Med. 1990; 112: 897–903</ref>
	**Though not accepted in common practice, new evidence suggest no significant risk and a benefit to using beta blockade in these patients<ref>Dattilo PB et al. β-blockers are associated with reduced risk of myocardial infarction after cocaine use. Ann Emerg Med. 2008; 51:117.</ref><ref>Finkel JB and Marhefka GD. Rethinking cocaine-associated chest pain and acute coronary syndromes. Mayo Clin Proc. 2011; 86(12):1198-1207. </ref><ref> Rangel C, et al. Marcus GM. Beta-blockers for chest pain associated with recent cocaine use. Arch Intern Med. 2010; 170(10):874-879.</ref>		**Though not accepted in common practice, new evidence suggest no significant risk and a benefit to using beta blockade in these patients<ref>Dattilo PB et al. β-blockers are associated with reduced risk of myocardial infarction after cocaine use. Ann Emerg Med. 2008; 51:117.</ref><ref>Finkel JB and Marhefka GD. Rethinking cocaine-associated chest pain and acute coronary syndromes. Mayo Clin Proc. 2011; 86(12):1198-1207. </ref><ref> Rangel C, et al. Marcus GM. Beta-blockers for chest pain associated with recent cocaine use. Arch Intern Med. 2010; 170(10):874-879.</ref>
	*Consider NaHOC3 for Ventricular Arrythmias immediately following cocaine use		*Consider [[NaHOC3]] for Ventricular Arrythmias immediately following cocaine use
	**Reverses cocaine induced QRS prolongation by Na channel blockade		**Reverses cocaine induced QRS prolongation by Na channel blockade

Rossdonaldson1: /* Evaluation */

2017-02-18T21:38:55Z

Evaluation

← Older revision		Revision as of 21:38, 18 February 2017
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	==Evaluation==		==Evaluation==
	*1-3hrs onset from last use		*1-3hrs onset from last use
	**If >3 hrs = lower risk of MI		**If >3 hrs = lower risk of [[AMI]]
	*Most with characteristic pain		*Most with characteristic pain
	*Dyspnea, diaploresis, and nausea		*Dyspnea, diaploresis, and nausea
	*Most have nl vitals		*Most have normal vitals

	==Management==		==Management==

Rossdonaldson1: /* See Also */

2017-02-18T21:37:47Z

Rossdonaldson1: /* Consider Admission= */

2017-02-18T21:37:27Z

Consider Admission=

← Older revision		Revision as of 21:37, 18 February 2017
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	**In NEJM 2/03; n=334; outcome of zero events at 30dys if no more cocaine		**In NEJM 2/03; n=334; outcome of zero events at 30dys if no more cocaine

	===Consider Admission====		===Consider Admission===
	*Persistent chest pain		*Persistent chest pain
	*[[ECG]] changes		*[[ECG]] changes

← Older revision		Revision as of 21:37, 18 February 2017
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	==See Also==		==See Also==
	*[[Cocaine]]		*[[Cocaine]]
	*[[Cocaine ~~intoxication~~]]		*[[Cocaine toxicity]]
	*[[Cocaine Withdrawal]]		*[[Cocaine Withdrawal]]
	*[[Acute Coronary Syndrome (Main)]]		*[[Acute Coronary Syndrome (Main)]]