Cocaine Chest Pain
· Cocaine is the 2nd most commonly used illicit drug in the US, 2nd to marijuana
· Incidence of cocaine associated MI is 0.6 – 7%
· Cocaine users have a lifetime risk of non fatal MI that is 7x the risk of non-users
· Pathophysiology of cardiotoxicity:
- Sympathomimetic, alpha adrenergic agonist, and prothrombotic
· 2008 AHA Guidelines:
- All patients get ASA and BDZs (Class IC and IB recommendation)
- STEMI: Unequivocally undergo cardiac catheterization
- NSTEMI/ACS: Manage similar to non cocaine chest pain patients except avoid B blockers
- Low-Moderate Risk: Observe in CPU for 9-12h.
- Based on data from a prospective study in 2003, NEJM, Weber et al.
- Always think of the patient’s cardiac risk factors independent of cocaine use to determine their risk.
· History: described as painful and burning.
· Patients at risk are those with underlying dermatoses, chronic immunosuppression
· PE: Umbilicated pustules that progress to punched-out erosions
· Usually have a recent HSV -1 exposure
· Look for eye involvement: herpes keratitis
· Treatment: oral acyclovir 400 mg PO tid
· May need admission if having severe pain
- Retrosternal pain (60%), odynophagia (50%), and dysphagia (40%)
· Common Causes:
- Antibiotics: Doxycycline, Tetracycline and Clindamycin
- Anti Inflammatory: ASA, NSAIDs
- Other Causes: Iron, Quinidine, KCl