What is the management of cocaine-induced chest pain (angina)?

From the Guidelines

Management of cocaine-induced chest pain requires prompt medical attention and a specific approach due to the unique cardiovascular effects of cocaine, with initial management focusing on benzodiazepines, aspirin, and avoidance of beta-blockers, instead using calcium channel blockers and nitroglycerin for vasodilation, as recommended by the most recent guidelines 1.

Key Considerations

• Cocaine-induced chest pain is a medical emergency that requires prompt attention due to the risk of myocardial infarction and other cardiovascular complications.
• The initial management should focus on reducing sympathetic stimulation and anxiety with benzodiazepines, such as diazepam 5-10 mg IV or lorazepam 1-2 mg IV.
• Aspirin 325 mg should be administered to prevent platelet aggregation.
• Beta-blockers should be avoided as they can worsen coronary vasoconstriction by leaving alpha-adrenergic effects unopposed.
• Calcium channel blockers like verapamil (5-10 mg IV) or diltiazem (0.25 mg/kg IV) can help reduce coronary vasospasm.
• Nitroglycerin (0.4 mg sublingual or IV infusion starting at 10 mcg/min) is also effective for vasodilation.

Diagnostic Approach

• Continuous cardiac monitoring is essential, and patients should be observed for at least 12 hours with serial ECGs and cardiac biomarkers.
• Troponin measurement is crucial for diagnosing myocardial infarction, as ECG changes may not always correlate with MI in cocaine users.
• Risk stratification using established criteria, such as changes on the ECG and troponin levels, is critical for determining the need for observation or inpatient admission.

Treatment

• For patients with confirmed myocardial infarction, standard reperfusion therapy should be considered.
• The use of beta-blockers is generally contraindicated in the acute setting of cocaine-induced chest pain due to the risk of worsening coronary vasoconstriction, as noted in several studies 1.
• The management of cocaine-induced chest pain differs from typical chest pain protocols due to the unique mechanisms by which cocaine causes chest pain, including increased myocardial oxygen demand, coronary vasospasm, enhanced platelet aggregation, and direct cardiac toxicity.

From the Research

Management of Cocaine-Induced Chest Pain

The management of cocaine-induced chest pain involves several pharmacological agents, including:

• Benzodiazepines, such as lorazepam, which have been shown to be effective in relieving cocaine-associated chest pain when used in combination with nitroglycerine 2
• Nitroglycerine, which is commonly used to treat chest pain, but may not be sufficient on its own to relieve cocaine-induced chest pain 2, 3
• Calcium-channel blockers, which are advocated as first-line drugs for managing cocaine-induced chest pain, and may be effective in reversing microvascular dysfunction 3, 4
• Labetalol, whose role in managing cocaine-induced chest pain is controversial and warrants further investigation 3

Treatment Approaches

Treatment approaches for cocaine-induced chest pain may involve:

• The use of sublingual nitroglycerine, with or without the addition of benzodiazepines, such as lorazepam 2
• The administration of intracoronary calcium-channel blockers to ameliorate microvascular spasm 4
• The use of dexmedetomidine or benzodiazepines, such as midazolam, to manage patients with signs and symptoms of acute cocaine intoxication 5
• The consideration of cardiac transplantation for patients with severe cardiovascular disease caused by cocaine use 5

Clinical Considerations

Clinical considerations in the management of cocaine-induced chest pain include:

• The potential for electrocardiographic findings to be misleading in terms of diagnosing a myocardial infarction 3, 6
• The need for careful evaluation and management of patients with cocaine-induced chest pain, given the complexity of the clinical scenario and the potential for adverse outcomes 3, 6