Makindo Medical Notes

Related Subjects: |Assessing Chest Pain |Acute Coronary Syndrome (ACS) General |Aortic Dissection |Pulmonary Embolism |Acute Pericarditis |Diffuse Oesophageal Spasm |Gastro- oesophageal reflux |Oesophageal Perforation Rupture |Pericardial Effusion_Tamponade |Pneumothorax |Tension Pneumothorax |Shingles

In patients presenting with cocaine-induced chest pain, prioritize intravenous nitrates or sodium nitroprusside to manage ischemic pain and hypertension. Beta-blockers should be avoided, as their unopposed alpha-adrenergic effects can exacerbate hypertension and coronary vasospasm.

About

• Cocaine is a potent stimulant commonly abused in various forms (e.g., crack cocaine when smoked).
• Patients may not volunteer a history of cocaine use; a thorough social and drug history is essential.
• Avoid using beta-blockers in these patients due to the risk of unopposed alpha-adrenergic vasoconstriction.

Cocaine

• Routes of Administration: Smoked (crack) for intense, rapid effects, or nasally inhaled (snorted) for a somewhat slower onset.
• Pharmacology: Cocaine blocks the reuptake of norepinephrine, dopamine, and serotonin, causing sympathomimetic effects.
• Cardiovascular Effects: Coronary vasospasm, increased myocardial oxygen demand, and potential for accelerated atherosclerosis.

Clinical Features

• Chest Pain: Often severe and central, mimicking acute coronary syndrome (ACS).
• Vital Signs: Hypertension, tachycardia, and potentially arrhythmias are common.
• Neurological Signs: Dilated pupils, agitation, anxiety, and delirium can indicate recent use.
• Other Considerations: Chronic use can lead to structural heart changes and exacerbate underlying coronary artery disease.

Investigations

• ECG: Almost always abnormal in cocaine-induced chest pain, may show ischemic changes (e.g., ST depression, T-wave inversions) or arrhythmias.
• Biochemical Markers:
  • ↑ CK (Creatine Kinase) is elevated in up to half of patients with cocaine-related chest pain, even without confirmed myocardial infarction (MI).
  • ↑ Troponin T and/or I may indicate myocardial injury.
• Echocardiogram: May show regional wall motion abnormalities suggesting ischemia or infarction.
• Toxicology Screen: Urine or blood tests can confirm cocaine exposure, though clinical suspicion should not be delayed while awaiting results.

Consult a cardiologist if there is ongoing pain, ECG changes, or uncertainty about optimal management. Early cardiology input can help guide the need for urgent percutaneous coronary intervention (PCI).

Management

• Avoid Beta-Blockers: The risk of unopposed alpha-adrenergic activity can worsen coronary vasospasm and hypertension.
• Nitrates and Vasodilators: Use IV nitrates or sodium nitroprusside to relieve vasospasm and chest pain. These agents help improve coronary blood flow and reduce blood pressure.
• Benzodiazepines: Administer benzodiazepines (e.g., diazepam or lorazepam) to alleviate anxiety, agitation, and sympathetic overdrive, which can help control blood pressure and heart rate.
• Supportive Care: Provide high-flow oxygen, aspirin for potential ACS management, and consider intravenous fluids if needed.
• Advanced Intervention: If pain persists, ECG abnormalities worsen, or troponins are elevated, consult cardiology promptly for possible PCI.
• Avoid Thrombolysis: Thrombolytic therapy poses a high risk of hemorrhagic stroke in the setting of cocaine use; PCI is preferred if indicated.
• Treat Underlying Issues: Address ongoing cocaine abuse through counseling, referral to addiction services, and social support as part of the long-term management strategy.