What Do I Do Differently for a Patient Presenting With an Acute Coronary Syndrome Who Tests Positive for Cocaine?

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target=""> Pediatrics</a> </li> <li class="first"> <a class="all" href="/web/20130807231821/http://www.healio.com/psychiatry/careers" title="News" target=""> Psychiatry</a> </li> <li class="first"> <a class="all" href="/web/20130807231821/http://www.healio.com/rheumatology/careers" title="News" target=""> Rheumatology</a> </li> <li class="first"> <a class="all" href="/web/20130807231821/http://www.healio.com/sports-medicine/careers" title="News" target=""> Sports Medicine</a> </li> </ul> </li> </ul> <script type="text/javascript"> jQuery(".nav>li:last>a").addClass("last"); //fix for IE last-child style </script>   <div id="main-content">  <p id="breadcrumbs"> <a href="/web/20130807231821/http://www.healio.com/"> Healio</a> <span>›</span> <a href="/web/20130807231821/http://www.healio.com/curbside-consultation"> Curbside Consultation</a> </p>  <div class="content"> <h2> What Do I Do Differently for a Patient Presenting With an Acute Coronary Syndrome Who Tests Positive for Cocaine?</h2> <p class="curbside-author"> Venkat P. Gundareddy, MD</p> <p class="curbside-author"> Shaker M. Eid, MD</p> <p>Cocaine is an illicit drug widely used and increasingly associated with chest pain and acute coronary syndrome (ACS) in younger urban populations. The mechanisms by which cocaine induces acute coronary syndrome are multiple. Increased myocardial oxygen demand, decreased oxygen supply via vasoconstriction, accelerated atherosclerosis, and a prothrombotic state all contribute to acute coronary syndrome after cocaine use. Management of these patients is mostly similar to other ACS patients who are not exposed to cocaine except in certain aspects pertaining to pharmacological/ pathophysiological effects of cocaine. Cocaine also has direct cardiotoxicity in chronic users with a higher incidence of myocardial damage, even in asymptomatic patients. Concurrent infections, such as with HIV, also increase incidence of cardiac disease. Though cocaine might be the trigger to precipitate an ACS, the underlying risk factors are the same as in the general population.</p> <p><strong>Clinical Characteristics</strong></p> <p>The clinical presentation of cocaine-associated ACS is similar to other patients with ACS. However, the patients are non-White, younger, and are more frequently male than the typical ACS population. The onset of ischemic symptoms can occur many hours after the ingestion of cocaine due to cocaine metabolites. However, risk of ACS is highest within the first hour of cocaine use. Studies have shown an increased risk of ACS even weeks after stopping cocaine. Prior baseline coronary artery disease, risk factors for having cardiac disease like diabetes, hypertension, peripheral vascular disease, dyslipidemia, tobacco use, alcohol use, and other structural heart diseases all incrementally increase the risk of ACS in cocaine abusers. Apart from the usual cardiac symptoms, patients can also present with neurological symptoms from the effects of cocaine. Other clusters of symptoms that can present are symptoms from vasospasm of non-coronary arteries and hypertensive urgency/emergency. The initial electrocardiogram combined with the history and laboratory evaluation would help in dividing the ACS into ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation MI (NSTEMI), or unstable angina (UA). Some of the frequent 12-lead electrocardiographic (ECG) findings, found in the younger, cocaine-abusing population, include the early repolarization pattern and left ventricular hypertrophy pattern that may make it more difficult to diagnose MI in these patients. Not surprisingly, the sensitivity and specificity of ECG for diagnosing cocaine-associated MI are lower than in the general population.<sup>1</sup></p> <p><strong>Initial Management</strong></p> <p>On initial presentation, ACS patients testing positive for cocaine (or who state they have consumed cocaine) should be assessed for hemodynamic stability. Hemodynamically unstable patients should be managed accordingly (eg, fluids, pressors, cardiopulmonary resuscitation, etc). In stable patients, the next step would be pain management and monitoring for arrhythmias. These patients should receive intravenous benzodiazepines and supplemental oxygen apart from aspirin and nitroglycerin. Intravenous benzodiazepines are beneficial for relieving both the cardiac hemodynamic effects (eg, hypertension, tachycardia) and neuropsychiatric effects (eg, anxiety, agitation) of cocaine. The dose of benzodiazepine is variable depending on the patient. When hypertension is present and does not respond to benzodiazepines it should be treated with nitroprusside or phentolamine. The next line of medications should be a calcium channel blocker. Beta-blockers should be avoided given the risk of worsening vasoconstriction due to unopposed alpha adrenergic effect. The  American College of Cardiology/American Heart Association (ACC/AHA) STEMI guidelines advise against administering beta-blockers in cocaine-induced STEMIs. However, in other patients, where blood pressure is not controlled with aforementioned medications, labetalol can be used to control the blood pressure. Sinus tachycardia frequently present in these patients usually responds to benzodiazepines and pain management. Other dysrhythmias noted on presentation are supraventricular tachycardia (SVT) and ventricular dysrhythmias. SVT may be managed with adenosine/calcium channel blockers as needed. Ventricular dysrhythmia occurring shortly after use of cocaine is due to its effect on myocardial sodium channels. Bicarbonate therapy is effective in these cases. Ventricular dysrhythmias occurring several hours after ACS and cocaine use are still likely from ischemia, and therapy with agents like lidocaine or amiodarone are appropriate. All dysrhythmias with hemodynamic instability should have cardioversion or defibrillation to restore sinus rhythm. Troponin is the cardiac biomarker of choice in these cases as creatine kinase levels can be elevated from rhabdomyolysis. A sudden rise and fall in cardiac enzymes is not consistent with an evolving MI; however, a gradually increasing troponin is consistent with an evolving MI.<sup>1</sup></p> <p><strong>Cocaine-Induced ST-Segment Elevation Myocardial Infarction</strong> </p> <p>In patients with >1 mm ST elevation, persistent chest pain, and positive cardiac enzymes, initiation of reperfusion therapy should be sought immediately. Percutaneous coronary intervention (PCI) should be the reperfusion therapy of choice (early invasive strategy). Fibrinolytic therapy is best reserved for patients who have strict contraindications for PCI. There are reports of fatal outcomes from intracranial hemorrhage after fibrinolytic therapy. The choice of revascularization procedure after angiography depends on the location and extent of disease. In patients with more severe disease, coronary artery bypass graft (CABG) should be pursued. Cocaine-induced STEMI patients have lower mortality than other STEMI patients. Patients with lower plaque burden should be treated with medical management and aggressive secondary prevention measures.</p> <p><em>Percutaneous Coronary Intervention</em></p> <p>Cardiac catheterization, and PCI if necessary, is recommended for cocaine-related STEMI patients and in high-risk NSTEMIs/UA patients as a part of early invasive strategy. Studies have shown that chronic cocaine use can cause premature atherosclerosis and increased plaque burden in normal patients. Coronary intervention with stent placement depends on a multitude of factors. Apart from the factors regularly considered before intra coronary stenting (ICS), effects of long-term use of cocaine on stent restenosis and compliance issues also need to be considered. Bare metal stents have been shown to have high incidence of in-stent restenosis in cocaine-abusing patients.<sup>2</sup> No data are available with drug eluting stents (DES) in this population. Bare metal stents should still be the preferred ICS in these patients with poor adherence; however, DES should be preferred in patients with a strong likelihood of adherence after very careful screening. Given ICS options have not yet been standardized in these patients, coronary artery bypass graft surgery or medical management should be preferred over ICS when appropriate. Like coronary vasospasm, cocaine can induce vasospasm in other major arteries, dissection of the aorta and/or coronary arteries, as well as coronary ectasia and aneurysms that complicate PCI.</p> <p><strong>Cocaine-Induced Non-ST-Segment Elevation MI and Unstable Angina</strong></p> <p>Similar to non-cocaine abusing patients with ACS, appropriate antithrombotic therapy and antiplatelet therapy should be initiated immediately with risk stratification per ACC/AHA guidelines. Patients with NSTEMI who have hemodynamic instability, severe LV dysfunction or heart failure, mechanical complications of MI (eg, ruptured papillary muscle, ventricular septal defect), or sustained ventricular arrhythmias should go for immediate PCI. Patients with unstable angina and other high-risk NSTEMI groups would benefit from an early invasive approach with cardiac catheterization. Post-cardiac catheterization, medical management, and secondary prevention should be initiated. Patients in low- to intermediate-risk groups should undergo either cardiac imaging (cardiac CT/MRI) or stress testing for further coronary artery disease evaluation and further risk stratification. </p> <p><em>Cardiac Imaging and Stress Testing</em></p> <p>Cardiac imaging or stress testing is important in patients with low- to intermediate-risk unstable angina/NSTEMI. Cardiac CT should be considered in patients younger than age 70 with no prior cardiac disease as it can effectively rule out coronary artery disease.<sup>3</sup> Stress testing is preferable in patients with higher suspicion for CAD. Stress echocardiography might be suboptimal since patients using cocaine are prone to having concentric left ventricular hypertrophy, which can decrease the test sensitivity by masking ischemia-induced regional wall motion abnormalities.<sup>4</sup></p> <p><strong>Medical Management and Secondary Prevention</strong></p> <p>Patients with no contraindications should have aggressive medical management for risk factor modification. This includes HMG-CoA-reductase inhibitors for dyslipidemia, aspirin therapy, and a thienopyridine, such as clopidogrel, for those higher risk ACS patients for 9 to 12 months or duration based on whether a bare metal or DES was used in the case of PCI. Beta-blockers like carvedilol, due to its alpha and beta-blocker properties, should be considered at discharge for patients who have LV dysfunction or significant coronary artery disease. Hypertension management with antihypertensive agents, cessation of cocaine use (most important), smoking cessation, hypertension control, diabetes control, diet and exercise, and weight reduction in overweight patients should all be addressed. </p> <p><strong>Complications</strong></p> <p>All the complications that arise with ACS are also seen with patients who test positive for cocaine. However, cocaine-induced ACS patients are prone to complications from comorbidities such as HIV from drug use, infective endocarditis, alcoholism, etc. Patients who continue to use cocaine post discharge have a higher risk of having future ACS. Other complications from cocaine such as aortic dissection, coronary artery aneurysms, and pulmonary edema are also seen. Dilated cardiomyopathy, atrial fibrillation, atrial flutter, SVT, ventricular tachyarrhythmia, bradycardia, and conduction delays are all seen from direct effect of cocaine on the heart. Finally, neuropsychiatric issues like agitation and anxiety also complicate the hospitalization in patients with cocaine-induced ACS.</p> <p><strong>Summary</strong></p> <p>Treatment of ACS in cocaine-abusing patients differs slightly from the non-cocaine using patients in the use of benzodiazepines and avoidance of beta-blockers in the early phase in favor of agents like phentolamine or nitroprusside when hypertension persists. Recognition of cocaine use to institute appropriate therapy, counseling, and anticipation of late side effects is essential. It also helps to define the most appropriate revascularization strategy (CABG vs PCI with BMS or DES) and revascularization vs medical therapy.</p> <p><strong>References</strong></p> <p>1. Hollander JE, Henry TD. Evaluation and management of the patient who has cocaine-associated chest pain. <em>Cardiol Clin</em>. 2006;24(1):103-114.</p> <p>2. Karlsson G, Rehman J, Kalaria V, Breall JA. Increased incidence of stent thrombosis in patients with cocaine use. <em>Catheter Cardiovasc Interv</em>. 2007;69(7):955-958.</p> <p>3. Paraschin K, Guerra De Andrade A, Rodrigues Parga J. Assessment of myocardial infarction by CT angiography and cardiovascular MRI in patients with cocaine-associated chest pain: a pilot study. <em>Br J Radiol</em>. 2012;85(1015):e274-e278. </p> <p>4. McCord J, Jneid H, Hollander JE, et al. 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What Do I Do Differently for a Patient Presenting With an Acute Coronary Syndrome Who Tests Positive for Cocaine?