The most important differences from management of non–cocaine-associated chest pain and MI are use of benzodiazepines and avoidance of beta-blockers for patients with hypertension and tachycardia.
The American Heart Association (AHA) has published a review of recent literature and recommendations for management of patients with cocaine-associated chest pain and myocardial infarction. Cocaine use leads to increased cardiac demand and accelerated atherosclerosis and coronary vasospasm. The AHA recommendations indicate that treatment of cocaine-associated myocardial ischemia differs in several important ways from treatment of non–cocaine-associated ischemia.
- Aspirin and nitrates continue to be strongly recommended as they are for non–cocaine-associated acute coronary syndrome (ACS), but β-blockers (including agents with mixed -adrenergic antagonist effects, such as labetolol) are considered contraindicated, despite a relatively weak evidence base. Theoretically, β-blockade might induce or worsen hypertension and vasospasm.
- If cocaine intoxication is suspected, benzodiazepines are recommended as the primary treatment for anxiety, tachycardia, and hypertension.
- Calcium channel blockers are not recommended. Some evidence from studies of patients with non–cocaine-associated ACS suggests that calcium channel blockers increase mortality rates when used as a first-line agent for control of hypertension.
- Early percutaneous coronary intervention is particularly preferred over fibrinolysis in patients with cocaine-associated MI because of increased risk for intracranial hemorrhage after administration of fibrinolytic agents in cocaine users.
Early aggressive treatment continues to be the mainstay of therapy for patients with suspected ACS. However, treatment for cocaine-associated ACS differs in several important ways from treatment for non–cocaine-associated ACS. Clarifying whether cocaine was recently used is important before administering β-blockers.
— Aaron E. Bair, MD, MSc, FAAEM, FACEP
Published in Journal Watch Emergency Medicine May 23, 2008
Citation(s): McCord J et al. Management of cocaine-associated chest pain and myocardial infarction: A scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Circulation 2008 Apr 8; 117:1897.