Cocaine Chest Pain

52yo M hx htn, hl, 'fluid in lungs' presenting with CP + SOB x1week. Incidentally pt was assaulted with fist in an attempted robbery yesterday AM, states CP is now worse and he was SOB all nite. 7/10 substernal sharp intermittent pain, radiating to R shoulder, associated with mild SOB. denies other symptoms asides from mild HA, R shoulder and elbow pain from assault. 

PMHx as stated. SurgHx -cardiac cath years ago at OSH, he doesn't remember details

SHx - no etoh, no tobacco, +Crack - last use 4days ago. 

PE: heart and lungs are unremarkable - no murmurs, rales.

Mild TTP at R shoulder and elbow, mild decrease ROM 2/2 pain.  

neuro - 5/5 upper and lower motor, normal sensory

EKG: sinus Tachycardia with T wave inversions laterally(v4-v6). No old EKG for comparison. 

CXR: mild pulmonary vasculature congestion, normal size heart.

Labs - trop 0.19, myoglobin 200's, BNP 1200, UA +cocaine, other baseline labs within normal range. 

Outcome: Pt was given aspirin, SL NTGx3 -with relief of CP to 3/10; started on NTG gtt. IV Ativan. Heparin ordered. Cardiology consulted - they questioned administration of heparin since we "know the etiology of his CP"...(I thought to myself...really?!). Admission.

Teaching point: Etiology and Management of Cocaine-CP. 


Cocaine causes MI via:

(1) increasing myocardial oxygen demand by increasing heart rate, blood pressure, and contractility (via its sympathomimetic effect)

(2) decreasing oxygen supply via vasoconstriction

(3) inducing a prothrombotic state by stimulating platelet activation and altering the balance between procoagulant and anticoagulant factors 

(4) accelerating atherosclerosis.

FYI -Cocaine use is reported as positive when the level of benzoylecgonine is above a standard cut-off value (usually 300 ng/mL). As benzoylecgonine has a urinary half-life of 6 to 8 hours, it can be detected in the urine for about 24 to 48 hours after cocaine use. Always ask for drug hx in CP pt. check UA if suspicious, cant get a hx or hx is unreliable even if the pt SWEARs 'they've never seen cocaine ever"

Management: 

1. Avoid BetaBlockers!!!! (a discussion for another day ) 

2. GIVE IV benzodiazepines early - will improve chest pain and hemodynamics while controlling anxiety!

3."We recommend aspirin be routinely administered and unfractionated heparin or low-molecular-weight heparin be given to patients with cocaine-associated MI unless there is a contraindication." -AHA guidelines for mgt of cocaine-CP/MI.


In summary for Cocaine-CP/MI, think of the way u'd manage a classic ACS(STEMI, NSTEMI or UA) case, add IV benzo, subtract IV Bblockers!
1. oxygen 2. aspirin 3. IV benzo 4. Nitroglycerin -for pain relief and BP control -will also reduce vasospasm/constriction; if SL NTG doesn't work, move to nitro drip 5. Heparin -unfractionated or LMWH 6. Call your cardiologist, Admit the patient.


See references HERE