How to manage a patient with low ejection fraction (EF) and a history of cocaine abuse?

Management of Low Ejection Fraction with Cocaine Abuse

Beta-blockers should be used in patients with heart failure and reduced ejection fraction (HFrEF) who have a history of cocaine abuse, as they improve functional status, ejection fraction, and reduce hospitalizations without increasing adverse cardiovascular events, despite traditional concerns about their use in this population. 1, 2

Acute vs. Chronic Cocaine Use: Critical Distinction

The management approach fundamentally differs based on timing of cocaine use:

Acute Cocaine Intoxication (within 72 hours)

• Avoid beta-blockers due to risk of unopposed alpha-adrenergic stimulation causing coronary vasospasm 3, 4, 5
• Use benzodiazepines as first-line therapy for hypertension, tachycardia, and agitation 5, 6
• Add nitroglycerin or calcium channel blockers (e.g., diltiazem 20 mg IV) for chest pain or persistent hypertension 3
• Consider dexmedetomidine if benzodiazepines fail to achieve hemodynamic stability 6

Chronic Heart Failure Management (remote cocaine use)

• Initiate beta-blocker therapy as part of guideline-directed medical therapy for HFrEF 1, 2
• Beta-blockers improve NYHA functional class (p < 0.0001) and LVEF (p < 0.0001) at 12 months 2
• Reduce 30-day heart failure readmissions by 83% (OR: 0.17,95% CI = 0.05-0.56) 7
• Lower risk of cocaine-related cardiovascular events (p = 0.0086) 1

Evidence-Based Treatment Algorithm

Step 1: Assess Timing of Last Cocaine Use

• If <72 hours: Follow acute intoxication protocol (benzodiazepines, avoid beta-blockers) 4, 5
• If >72 hours or chronic use: Proceed with standard HFrEF management including beta-blockers 1, 2

Step 2: Initial Stabilization for Acute Presentation

• Benzodiazepines (diazepam or clonazepam) for 7-14 days to control agitation, insomnia, and craving 4
• Monitor cardiac biomarkers: Use troponin I or troponin T (more specific than CK-MB which can be elevated from rhabdomyolysis) 3
• Serial troponin measurements at 3,6, and 9 hours if chest pain present 3
• 24-hour monitored observation if ECG shows ST-segment changes with normal biomarkers 3

Step 3: Long-Term HFrEF Management

• Beta-blocker therapy is safe and beneficial despite active cocaine use 1, 2, 8
• Improves NYHA functional class and LVEF significantly 2
• Reduces heart failure hospitalizations (p = 0.0383) 1
• No major adverse cardiovascular events observed in multiple studies 2, 8

Step 4: Address Cocaine Dependence

• Naltrexone 50 mg/day to reduce cocaine craving and prevent relapse 4
• Treat coexisting psychiatric disorders (depression, anxiety, bipolar disorder) which are common 4
• Monitor closely for exacerbation of depressive symptoms during abstinence 4

Revascularization Considerations

If coronary intervention needed:

• Prefer bare-metal stents over drug-eluting stents due to shorter required duration of dual antiplatelet therapy 3
• Cocaine users are often unreliable with medication adherence, increasing in-stent thrombosis risk with DES 3
• PCI preferred over fibrinolysis when available, as cocaine users frequently have contraindications to thrombolytics (hypertension, seizures, aortic dissection) 3

Common Pitfalls to Avoid

• Do not reflexively avoid beta-blockers in all cocaine users - the evidence shows benefit in chronic HFrEF with remote or ongoing use 1, 2, 8
• Do not use beta-blockers within 72 hours of acute cocaine use - this is when unopposed alpha-stimulation risk is highest 4, 5
• Do not rely on CK-MB alone for MI diagnosis - cocaine causes rhabdomyolysis that elevates CK-MB without myocardial injury 3
• Do not assume MI in all cocaine-related chest pain - only 6% develop actual MI 3

Advanced Heart Failure Considerations

For severe cocaine-induced cardiomyopathy:

• Inotropic support (milrinone) may be needed for acute decompensation 6
• Cardiac transplantation should be considered for severe cardiovascular disease refractory to medical therapy 6
• Cessation of cocaine use is essential for transplant candidacy 6

Monitoring Strategy

• Serial assessment of NYHA functional class and LVEF at 12-month intervals on beta-blocker therapy 1, 2
• Screen for ongoing cocaine use with urine toxicology 7
• Monitor vital signs closely if cardiovascular complications history present 4
• Evaluate for cocaine-related complications: accelerated atherosclerosis, myocarditis, cardiomyopathy, aortic/coronary dissection 3