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

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


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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