What is the treatment for cocaine-associated myocardial infarction (Myocardial Infarction, MI)?

From the Guidelines

Treatment of cocaine-associated myocardial infarction requires immediate medical attention with specific modifications to standard heart attack protocols, prioritizing calcium channel blockers and nitroglycerin over beta-blockers due to the risk of worsening coronary vasoconstriction 1.

Key Considerations

• First-line treatment includes benzodiazepines to reduce sympathetic stimulation, followed by aspirin and nitroglycerin to alleviate anginal symptoms.
• Beta-blockers should be avoided initially as they can worsen coronary vasoconstriction by leaving alpha-adrenergic effects unopposed, as noted in a study published in Circulation 1.
• Calcium channel blockers like verapamil or diltiazem are preferred for reducing hypertension and coronary vasospasm, with a study in the Journal of the American College of Cardiology supporting their use 1.
• Percutaneous coronary intervention is the preferred reperfusion strategy for STEMI, while thrombolytics should be used cautiously due to increased bleeding risk with cocaine.

Management Strategies

• Patients with unstable angina and non–ST-segment–elevation MI not precipitated by cocaine use may benefit from selective use of the combination of aspirin and clopidogrel, as suggested by a scientific statement from the American Heart Association 1.
• Nitrates and calcium channel blockers may be administered to treat anginal symptoms but are not indicated for routine use.
• Angiotensin-converting enzyme inhibitors should be used in patients with left ventricular systolic dysfunction.
• Postdischarge use of beta-blockers should be reserved for those with the strongest indications, including those with documented MI, left ventricular systolic dysfunction, or ventricular arrhythmias, and should be individualized on the basis of careful risk–benefit assessment and after counseling the patient about the potential negative interactions between recurrent cocaine use and beta-blockade 1.

Additional Recommendations

• Addressing the underlying cocaine use disorder through referral to addiction treatment is essential for preventing recurrence, as cocaine causes myocardial infarction through multiple mechanisms including coronary vasospasm, increased oxygen demand, enhanced platelet aggregation, and accelerated atherosclerosis.
• Patients should receive standard post-MI care including dual antiplatelet therapy, statins, and ACE inhibitors, with careful consideration of the potential risks and benefits of each medication in the context of cocaine use.

From the FDA Drug Label

Clopidogrel tablets are indicated to reduce the rate of myocardial infarction (MI) and stroke in patients with non–ST-segment elevation ACS (unstable angina [UA]/non–ST-elevation myocardial infarction [NSTEMI]), including patients who are to be managed medically and those who are to be managed with coronary revascularization Clopidogrel tablets are indicated to reduce the rate of myocardial infarction and stroke in patients with acute ST-elevation myocardial infarction (STEMI) who are to be managed medically.

The treatment for cocaine-associated myocardial infarction is not directly addressed in the provided drug labels. However, based on the indications for acute coronary syndrome (ACS) and myocardial infarction (MI), clopidogrel may be considered as part of the treatment regimen, in conjunction with aspirin, for patients with myocardial infarction, including those caused by cocaine use.

• The dosage for acute coronary syndrome is a single 300 mg oral loading dose, followed by 75 mg once daily.
• It is essential to note that clopidogrel is not specifically indicated for cocaine-associated myocardial infarction, and its use in this context would be based on the general management of myocardial infarction 2 2.

From the Research

Cocaine Associated Myocardial Infarction Treatment

• The treatment of cocaine-associated myocardial infarction (MI) presents unique challenges due to various mechanisms such as atherosclerotic plaque rupture, platelet activation, and coronary vasospasm 3.
• Initial treatment for patients with cocaine-associated myocardial ischaemia should include benzodiazepines to decrease central adrenergic stimulation, aspirin to reduce thrombus formation, and nitroglycerin to reverse coronary vasoconstriction 4.
• Patients with continued ischaemia can be treated with either low doses of phentolamine or verapamil, and if ischaemia continues, mechanical reperfusion or thrombolytic therapy should be considered depending on the clinical circumstances 4.
• Beta adrenergic antagonists should not be used in patients with myocardial ischaemia secondary to cocaine as they can enhance coronary vasoconstriction and worsen ischaemia 4.
• The general treatment of acute myocardial infarction includes interventions such as oxygen, sublingual nitroglycerin, morphine, aspirin, heparin, and intravenous nitroglycerin, as well as beta-adrenergic blockers, thrombolytic agents, and revascularization with either coronary angioplasty or bypass graft surgery 5.
• In the context of myocardial infarction, beta-blockers have been shown to reduce early mortality, reinfarction, and cardiac arrests, and are preferable to calcium channel blockers in the acute phase and long-term after myocardial infarction 6.