Cocaine-associated chest pain

Background

Cocaine is a catalyst for CAD & up to 6% of cocaine related CP develop an MI, however, a 9-12 hour period of ECG's and serial troponins can be safe. Of the 334 pts studied, if both were negative, no deaths from CV events occurred at 30 days. 4 pts did have non-fatal MI's but were using coc at the time (NEJM 2/03).

Epidemiology

• Causes vasculitis
• 6% incidence of AMI w/ cocaine CP
• Cocaine assoc c 24x risk of MI

Clinical Features

• Chest pain in the setting of cocaine or related stimulant use

DDx

Chest Pain (DDx)

Workup

nl CP w/o (see disposition)

Diagnosis

1. 1- 3hrs onset from last use
   1. if >3 hrs = lower risk of MI
2. Most with characterislnic pain
3. Dyspnea, diaploresis, and nausea
4. Most have nl vitals

Treatment

1. ASA, NTG, O2
2. Benzos
3. Consider Phentolamine or CCB (in benzo non responders)
4. Labetalol?
   1. Theoretical contra-indication B-blocker 2nd to unopposed alpha
5. Consider NaHOC3 for Ventricular Arrythmias immediately following cocaine use
   1. Reverses cocaine induced QRS prolongation by Na channel blockade

Disposition

1. May discharge after: 9-12 hour period of ECG's and serial troponins, if both are negative.
   1. NEJM 2/03; n=334; outcome of zero events at 30dys if no more cocaine

Risk Stratification

1. Lower:
   1. also low risk if ecg normal and without ischemic changes
   2. cocaine can however cause AMI, dilated cardiomyopathy, CHF

See Also

• Cocaine Withdrawal
• Acute Coronary Syndrome (Main)

Source

10/07 DONALDSON (adapted from Lampe, Mistry)

7/12 N Engl J Med. 1995 Nov 9;333(19):1267-72. (adapted from Colorado compendium)