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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Chest pain, myocarditis-like syndrome, and myocardial infarction

  • Features of congestive heart failure secondary to cocaine dilated cardiomyopathy

  • Hypertension

  • Positive history or urine drug screen for cocaine

  • ECG is often nonspecific (non–Q-wave infarction is more common than Q-wave infarction in cocaine users)

GENERAL CONSIDERATIONS

  • Cocaine is the most common illicit drug with major actions on the cardiovascular system

  • Cocaine increases vasoactive and cardiac-stimulating substances, causing peripheral and coronary artery constriction, tachycardia, and increased cardiac contractility

  • Myocardial ischemia and life-threatening ventricular arrhythmias may ensue

  • Irreversible structural damage to the heart eventually occurs

  • May accelerate existing atherosclerotic coronary artery disease

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Chest pain

  • Dyspnea

  • Syncope

PHYSICAL EXAM FINDINGS

  • Hypertension

  • Tachycardia

  • Increased respiratory rate

DIFFERENTIAL DIAGNOSIS

  • Atherosclerotic coronary artery disease

  • Spontaneous coronary artery spasm

  • Spontaneous coronary artery dissection

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Cocaine blood or urine screen

  • Elevated cardiac biomarkers, such as troponin, brain natriuretic peptide

ELECTROCARDIOGRAPHY

  • Nonspecific ST-T–wave changes

  • Ischemic ST-T–wave changes

  • Q-wave myocardial infarction less common

IMAGING STUDIES

  • Echocardiography: may show segmental wall motion abnormalities and reduced left ventricular function

  • Nuclear perfusion studies: may show patchy defects

DIAGNOSTIC PROCEDURES

  • Coronary angiography may be needed to exclude coronary artery disease

TREATMENT

CARDIOLOGY REFERRAL

  • Suspected myocardial ischemia/infarction

  • Serious ventricular arrhythmias

  • Cardiomyopathy present

HOSPITALIZATION CRITERIA

  • Acute coronary syndromes

  • Syncope or collapse

  • Significant arrhythmias

  • Severe hypertension

MEDICATIONS

  • Nitrates, alpha-adrenoreceptor blockers, and verapamil for acute ischemia

  • Aspirin

  • Thrombolytic therapy in acute ST-segment elevation myocardial infarction

  • Beta blockers are controversial, due to the fear of unopposed alpha stimulation, but clinical observations suggest they are well tolerated and can be useful

  • Type Ia and III antiarrhythmics are relatively contraindicated

  • Lidocaine should be used cautiously because it lowers the seizure threshold

THERAPEUTIC PROCEDURES

  • Emergent coronary angiography and primary angioplasty may be used as alternative means of establishing perfusion

  • Although often indicated, few get drug-eluting stents due to the uncertainty regarding whether they can commit to months of dual antiplatelet therapy

  • These patients are rarely candidates for cardiac transplantation

MONITORING

  • ECG monitoring in hospital as appropriate

DIET AND ACTIVITY

  • Low-sodium, low-fat diet

  • Restricted activities initially, then cardiac rehabilitation

ONGOING MANAGEMENT

HOSPITAL DISCHARGE CRITERIA

  • Resolution of problems

FOLLOW-UP

  • Depends on residual disease severity

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