Emergency Treatment for Severe Chest Pain from Cocaine Overdose

Initial Assessment and Risk Stratification

The American Heart Association recommends obtaining an immediate 12-lead ECG to determine the presence of ST-segment elevation, which fundamentally changes management strategy, in patients presenting with severe chest pain after cocaine use 1, 2
Patients with ST-segment elevation, ST-segment depression ≥1 mm, elevated cardiac markers, recurrent chest pain, or hemodynamic instability require direct admission to monitored beds, with approximately 24% developing MI and another 24% developing unstable angina 3
Young patients often have benign early repolarization that mimics ST-elevation, so only a small percentage with J-point elevation are actually having an MI, according to the American College of Cardiology 3

The American College of Cardiology recommends administering sublingual nitroglycerin or intravenous calcium channel blockers (diltiazem 20 mg IV) immediately for chest pain, along with benzodiazepines for agitation and hypertension, in patients with cocaine-associated chest pain 1, 2, 4
Both agents reverse cocaine-induced coronary vasoconstriction, hypertension, and tachycardia, with a strength of evidence level of I (high-quality evidence) 4
Aspirin should be administered as part of standard acute coronary syndrome management, according to the American Heart Association 3

For patients with ST-segment elevation, the American College of Cardiology recommends administering sublingual nitroglycerin or IV calcium channel blockers immediately, with a strength of evidence level of I (high-quality evidence) 1, 2, 4
If no response to vasodilators, proceed immediately to coronary angiography if available, with a strength of evidence level of IIa (moderate-quality evidence) 1, 2
PCI is strongly preferred over fibrinolytic therapy when available, as cocaine users frequently have contraindications to thrombolytics, according to the American Heart Association 1, 2, 3
If PCI is performed, use bare-metal stents rather than drug-eluting stents because cocaine users are unreliable with prolonged dual antiplatelet therapy adherence, creating high risk for in-stent thrombosis, with a strength of evidence level of IIb (low-quality evidence) 1, 2, 4

The American Heart Association recommends screening for life-threatening complications beyond MI, including aortic dissection, coronary artery dissection, myocarditis, and cardiomyopathy, which are all reported with cocaine use, with a strength of evidence level of I (high-quality evidence) 1
Avoid combined alpha- and beta-blocking agents (like labetalol) in the acute setting, though this may be reasonable in select circumstances (Class IIb recommendation), according to the American College of Cardiology 4

The American College of Cardiology recommends avoiding beta-blockers in patients with acute cocaine intoxication due to the risk of unopposed alpha-adrenergic stimulation causing coronary vasospasm 5, 6, 7
Benzodiazepines should be used as first-line therapy for hypertension, tachycardia, and agitation in patients with acute cocaine intoxication 7, 6
Nitroglycerin or calcium channel blockers, such as diltiazem 20 mg IV, should be added for chest pain or persistent hypertension in patients with acute cocaine intoxication 5, 8, 9

The American Heart Association suggests that beta-blocker therapy is safe and beneficial for patients with chronic heart failure and reduced ejection fraction, despite active cocaine use, improving NYHA functional class and LVEF 6
Naltrexone 50 mg/day can be used to reduce cocaine craving and prevent relapse in patients with cocaine dependence 6

The American College of Cardiology prefers bare-metal stents over drug-eluting stents for coronary intervention in cocaine users due to the shorter required duration of dual antiplatelet therapy 5, 8, 9
Percutaneous coronary intervention is preferred over fibrinolysis when available, as cocaine users frequently have contraindications to thrombolytics 5, 8, 9

Serial assessment of vital signs is crucial in patients with a history of cardiovascular complications 6
The American College of Cardiology recommends evaluating patients for cocaine-related complications, including accelerated atherosclerosis, myocarditis, cardiomyopathy, and aortic/coronary dissection 5, 8, 10