Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ 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... Your MyAccess profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth