American Heart Association Releases Guidelines on Treatment of Cocaine-Associated Chest Pain
There are approximately 500,000 cocaine-associated emergency department visits annually, and it is estimated that 40% involve chest pain. Cocaine increases heart rate and blood pressure, constricts the coronary arteries, induces a prothrombic state, and accelerates atherosclerosis. The American Heart Association conducted a systematic review of the literature to assist in the care of patients with cocaine-associated chest pain (CACP). Primary findings and recommendations are as follows:
- Myocardial infarction (MI) occurs in 0.7% to 6% of patients who present with CACP.
- Patients with CACP, unstable angina, or MI should be treated similarly to those with possible acute coronary syndrome, including the provision of aspirin. In addition, intravenous benzodiazepines should be provided.
- Persistent hypertension should be managed with sodium nitroprusside, nitroglycerin, or intravenous phentolamine.
- Patients at low risk (no electrocardiogram [ECG] changes and no elevation in cardiac troponins) can be safely observed in a chest pain observation unit for 6 to 12 hours.
- Patients at high-risk (ECG changes and elevated troponins) should be admitted to a telemetry bed. In these patients, ß-blockers should be avoided acutely, and antithrombic and antiplatelet therapy should be administered per standard guidelines.
- In all patients, substance abuse counseling should be part of discharge planning.
Comments:
The literature is limited due to the low number of randomized clinical trials or well-performed observational studies. Nonetheless, this review provides a useful compilation of the available literature on this topic.
David A. Fiellin, MD
Reference:
McCord J, Jneid H, Hollander JE, et al. Management of cocaine-associated chest pain and myocardial infarction: a scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Circulation. 2008;117(14):
1897–1907.