Cocaine-associated chest pain: Difference between revisions

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== Background ==
==Background==
 
*Cocaine causes vasoconstriction, which can precipitate MI
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).
**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>
 
*6% incidence of AMI with cocaine chest pain
=== Epidemiology  ===
*Cocaine associated with 24x risk of true MI
*Causes vasculitis
*Be aware of cocaethylene metabolites in the setting of EtOH use, will produce longer symptoms and potentially be more directly cardiotoxic
*6% incidence of AMI w/ cocaine CP
*Cocaine assoc c 24x risk of MI


==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


== DDx  ==
==Differential Diagnosis==
 
{{Chest Pain DDX}}
[[Chest Pain (DDx)]]
 
== Workup  ==
 
nl CP w/o (see disposition)
 
== Diagnosis  ==
 
#1- 3hrs onset from last use
##if &gt;3 hrs = lower risk of MI
#Most with characterislnic pain
#Dyspnea, diaploresis, and nausea
#Most have nl vitals
 
== Treatment  ==
 
#ASA, NTG, O2
#Benzos
#Consider Phentolamine or CCB (in benzo non responders)
#Labetalol?
##Theoretical contra-indication B-blocker 2nd to unopposed alpha
#Consider NaHOC3 for Ventricular Arrythmias immediately following cocaine use
##Reverses cocaine induced QRS prolongation by Na channel blockade
 
== Disposition  ==


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


=== Risk Stratification  ===
==Evaluation==
*1-3hrs onset from last use
**If >3 hrs = lower risk of [[AMI]]
*Most with characteristic pain
**Dyspnea, diaploresis, and nausea
*Most have normal vitals
*ECG


#Lower:  
==Management==
##also low risk if ecg normal and without ischemic changes
*[[ASA]]
##cocaine can however cause AMI, dilated cardiomyopathy, CHF
*[[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)
*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>
*Consider [[NaHOC3]] for Ventricular Arrythmias immediately following cocaine use
**Reverses cocaine induced QRS prolongation by Na channel blockade


== See Also  ==
==Disposition==
*Consider discharge after 9-12 hour observation if pain free, no EKG changes and negative serial troponin
**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


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


== Source  ==
==References==
 
<references/>
10/07 DONALDSON (adapted from Lampe, Mistry)
 
7/12 N Engl J Med. 1995 Nov 9;333(19):1267-72. (adapted from Colorado compendium)


[[Category:Cards]] [[Category:Tox]]
[[Category:Cardiology]]
[[Category:Toxicology]]

Latest revision as of 16:13, 26 March 2018

Background

  • Cocaine causes vasoconstriction, which can precipitate MI
    • Cocaine metabolites can persist for up to 24hrs and cause delayed or recurrent coronary vasoconstriction[1]
  • 6% incidence of AMI with cocaine chest pain
  • 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

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

Differential Diagnosis

Chest pain

Critical

Emergent

Nonemergent

Sympathomimetics

Evaluation

  • 1-3hrs onset from last use
    • If >3 hrs = lower risk of AMI
  • Most with characteristic pain
    • Dyspnea, diaploresis, and nausea
  • Most have normal vitals
  • ECG

Management

  • ASA
  • Benzos directed at symptom relief, not necessarily hypertension and tachycardia[1]
  • Consider Nitroglycerin, Nitroprusside, Phentolamine (1mg IV), or CCB (in benzodiazepine non-responders)
  • 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[2][3]
    • Though not accepted in common practice, new evidence suggest no significant risk and a benefit to using beta blockade in these patients[4][5][6]
  • Consider NaHOC3 for Ventricular Arrythmias immediately following cocaine use
    • Reverses cocaine induced QRS prolongation by Na channel blockade

Disposition

  • Consider discharge after 9-12 hour observation if pain free, no EKG changes and negative serial troponin
    • 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.[7]
  • Otherwise admit

See Also

References

  1. 1.0 1.1 McCord J, et al. Management of cocaine-associated chest pain and myocardial Infarction. Circulation. 2008; 117:1897-1907.
  2. Boehrer JD. et al. Influence of labetalol on cocaine-induced coronary vasoconstriction in humans. Am J Med. 1993; 94: 608– 610
  3. Lange RA. et al. Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade. Ann Intern Med. 1990; 112: 897–903
  4. Dattilo PB et al. β-blockers are associated with reduced risk of myocardial infarction after cocaine use. Ann Emerg Med. 2008; 51:117.
  5. Finkel JB and Marhefka GD. Rethinking cocaine-associated chest pain and acute coronary syndromes. Mayo Clin Proc. 2011; 86(12):1198-1207.
  6. Rangel C, et al. Marcus GM. Beta-blockers for chest pain associated with recent cocaine use. Arch Intern Med. 2010; 170(10):874-879.
  7. Kloner RA and Rezkalla SH. Cocaine and the heart. N Engl J Med. 2003; 348:487-488.