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 with cocaine-induced chest pain, give IV nitrates or sodium nitroprusside to relieve ischemia and hypertension. ❌ Avoid beta-blockers – they can cause unopposed alpha-adrenergic vasoconstriction, worsening coronary spasm and BP.

📖 About

• 🔬 Cocaine is a powerful sympathomimetic stimulant, often used as crack (smoked) or powder (snorted).
• 🧠 Acts by blocking reuptake of norepinephrine, dopamine, and serotonin, leading to intense sympathetic stimulation.
• ⚠️ A detailed social & drug history is essential as patients may not disclose use.

💉 Cocaine – Pharmacology & Effects

• Routes: Smoking → rapid & intense "rush"; Snorting → slower onset but longer duration.
• CV effects: Coronary vasospasm, ↑ myocardial O₂ demand, tachyarrhythmias, and accelerated atherosclerosis.
• Chronic use: Causes structural heart changes, LV hypertrophy, and predisposes to early CAD.

🩺 Clinical Features

• 💔 Chest pain – central, severe, ACS-like.
• 📈 Vitals: Hypertension, tachycardia, arrhythmias.
• 👁️ Neuro signs: Dilated pupils, agitation, anxiety, paranoia.
• 🫀 Other: Can precipitate MI, myocarditis, or sudden cardiac death.

🔎 Investigations

• ECG: Almost always abnormal – ischemic changes (ST ↓, T-wave inversion) or arrhythmias.
• Bloods:
  • ↑ CK – often elevated even without MI.
  • ↑ Troponin T/I – indicates myocardial injury.
• Echocardiogram: Regional wall motion abnormalities possible.
• Toxicology: Urine/blood screen may confirm cocaine but never delay treatment.

💡 Always consult cardiology early if chest pain persists, troponins rise, or ECG evolves → PCI preferred over thrombolysis.

⚕️ Management

• ❌ Avoid beta-blockers – risk of unopposed alpha vasospasm.
• 💊 Nitrates & vasodilators (IV GTN, sodium nitroprusside) → relieve coronary spasm & hypertension.
• 😌 Benzodiazepines (e.g., diazepam, lorazepam) → reduce agitation, anxiety, and sympathetic overdrive.
• 🫁 Supportive ACS care: O₂ if hypoxic, aspirin, IV fluids if hypotensive.
• 🫀 Advanced care: PCI if ongoing ischemia/MI; avoid thrombolysis (↑ risk of intracranial bleed in cocaine users).
• 🌱 Long-term: Address cocaine dependence – referral to addiction services, counseling, social support.

📚 Teaching Pearl

Cocaine chest pain is a classic "don’t give beta-blockers" scenario in exams 🚫. Remember: use nitrates + benzodiazepines, manage as ACS but think twice before thrombolysis. Always treat the patient and the addiction – otherwise the cycle will repeat. 🔄