Management of Cocaine-Associated Chest Pain and MI

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 α-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.