Management of Cocaine-Associated Chest Pain and Myocardial Infarction

Abstract

T he goals of the present article are to provide a critical review of the literature on cocaine-associated chest pain and myocardial infarction (MI) and to give guidance for diagnostic and therapeutic interventions. • Level of Evidence A: Data derived from multiple randomized clinical trials. • Level of Evidence B: Data derived from a single randomized trial or nonrandomized studies. • Level of Evidence C: Only consensus opinion of experts , case studies, or standard of care. Methods The Writing Committee conducted a comprehensive search of the medical literature concerning cocaine-associated chest pain and MI. The literature search included English-language publications on humans and animals from 1960 to 2007. In addition to broad-based searching concerning cocaine, specific targeted searches were performed on cocaine and the following topics: MI, chest pain, emergency department (ED), aspirin, nitroglycerin, calcium channel blocker, benzo-diazepine, thrombolytics, phentolamine, heparin, primary an-gioplasty, ECG, and stress testing. Literature citations were generally limited to published articles listed in Index Medi-cus. The article was reviewed by 4 outside reviewers nominated by the AHA. Epidemiology Cocaine is the second most commonly used illicit drug in the United States, with only marijuana being abused more frequently. 1 Cocaine is also the illicit drug that leads to the most ED visits. 2 The 2004 National Survey on Drug Use and Health estimated that 14% of people 12 years of age or older (34 million individuals) in the United States have tried cocaine at least once, 3 and over 2000 individuals per day use cocaine for the first time. 4 In the 2002 to 2003 calendar year, more than 1.5 million (0.6%) Americans 12 years of age had abused cocaine in the past year. Cocaine use is concentrated among select demographics: individuals 18 to 25 years of age (1.2%) have the highest rate of cocaine use; males (0.9%) had more than twice the use rate of females (0.4%); and rates according to race are 1.1% for blacks, 0.9% for Hispanics, 0.5% for whites, and 0.1% for Asians. 6 In 2005, there were 448 481 cocaine-related visits to EDs in the United States. 7 Chest discomfort has been reported in 40% of patients who present to the ED after cocaine use. 8 The The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.