Cocaine-related Chest Pain

Reviewed and revised 20 May 2016

OVERVIEW

• Cocaine is a recreational drug with sympathomimetic effects in additional to being a sodium channel blocker
• Cocaine can induce acute coronary syndromes through vasoconstriction, atheroma rupture and/ or dissection
  • Cocaine contributes to approx. 1 of every 4 MIs between 18 and 45 years of age in the USA
  • 0.7%-6% of patients presenting to the ED with chest pain during or immediately after using cocaine will rule in for an MI based on cardiac biomarkers
  • risk of MI rises as much as 24-fold during the first hour after cocaine use
• Cocaine-related vasoconstriction can still cause acute MI hours or as many as 4 days later (rarely)

CLINICAL FEATURES

• Chest pain is not reliably present in patients with cocaine-associated MI
  •  only 44% of patients with cocaine-associated MI had chest pain (Hollander and Hoffman, J Emerg Med 1992)
• Dyspnea and diaphoresis are other common symptoms that should prompt concern for acute MI if chest pain is not present
• Cocaine-associated MI usually occurs fairly early after acute cocaine use
  • 50% of MIs occur in patients prior to their arrival in the ED
  • 24% of the total will occur within the first hour of cocaine use
• ocaine causes systolic and diastolic dysfunction, arrhythmias, and atherosclerosis even in young users with relatively few cardiac risk factors, typically TIMI risk score <1

MANAGEMENT

Rule out aortic dissection

Treat suspected acute coronary syndrome

• Aspirin (and other anti platelets depending on your hospital protocols)
• Nitroglycerine
• Calcium channel antagonists
• Coronary angiography +/- stenting – if  ST elevation that persists after medical treatment
• Avoid beta-blockers (including labetolol) due to risk of unopposed alpha-agonism
• Thrombolytics are contraindicated if severe hypertension, seizures, intracerebral haemorrhage or aortic dissection

Standard chest pain pathways are adequate for ruling out ACS as events rarely occur later

• If a patient has not ruled in by 12 hours post-arrival in the ED, it is extremely unlikely that the patient will rule in or suffer ACS-related complications from the cocaine

Follow up

• cessation of cocaine use
• If the patient discontinues using cocaine, the prognosis for absence of subsequent cardiac events is excellent

EVIDENCE FOR THE CONTRA-INDICATION OF BETA-BLOCKERS IN COCAINE-INDUCED CHEST PAIN

Several retrospective studies have concluded that beta blockers are safe in cocaine induced chest pain

• subject to selection and measurement bias
• some studies base diagnosis of cocaine-induced chest pain on the presence of positive cocaine drug screens, these may be persistently positive for up to 3 days after acute intoxication has resolved

Lange et al, 1990

• randomized, double-blind, placebo controlled trial
• n = 30 (38- 68 years old) patients undergoing cardiac catherization for chest pain evaluation
• Cocaine (intranasal administration) resulted in:
  • Increased myocardial oxygen demand
  • Increased coronary vascular resistance 22%
  • Decreased coronary sinus blood flow: 10%
• Addition of propanolol (intra-coronary infusion) resulted in:
  • Increase coronary vascular resistance 19%
  • Decrease coronary sinus blood flow by 15%
  • No additional change in myocardial oxygen demand
  • Complete coronary occlusion observed in 1 patient with ST elevation
  • Epicardial coronary arterial segment constriction >10% in 5 patients.
• Conclusion
  • “Unopposed alpha effect” does occur in coronary artery when a beta-blocker is administered in a setting of acute cocaine exposure.
  • beta-blocker use is best avoided in the acute management of cocaine-induce acute chest pain

References and Links

LITFL

• CCC — Cocaine toxicity

Journal articles

• Lange RA, Cigarroa RG, et al. Pontetiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade. Ann Internal Med 1990;112:897-903
• McCord J, et al. Management of cocaine-associated chest pain and myocardial infarction. Circulation 2008;117:897-1907.
• Schwartz B, et al. Cardiovascular Effects of Cocaine.  Circulation. 2010;122:2558-2569.
• Rezkalla SH, Kloner RA. Cocaine-induced acute myocardial infarction. Clin Med Res. 2007 Oct;5(3):172-6. Review. PubMed PMID: 18056026; PubMed Central PMCID: PMC2111405.
• Weber JE, Shofer FS, Larkin GL, Kalaria AS, Hollander JE. Validation of a brief observation period for patients with cocaine-associated chest pain. N Engl J Med. 2003 Feb 6;348(6):510-7. PubMed PMID: 12571258. [Free Fulltext]

FOAMand web resources

• UMEM Education Pearls — Cocaine Chest Pain by Amal Mattu
• Free EM Talks — Cocaine-Related Cardiac Toxicity in the ED – David Wood (UK)
• Free EM Talks — Cocaine Myocardial Ischemia – Judd E. Hollander (USA)