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. 🔄
