Every year more than 500,000 patients present to the emergency department with cocaine-associated complications, most commonly chest pain. Many of these patients undergo extensive work-up and treatment. Much of the evidence regarding cocaine's cardiovascular effects, as well as the current management of cocaine-associated chest pain and acute coronary syndromes, is anecdotally derived and based on studies written more than 2 decades ago that involved only a few patients. Newer studies have brought into question many of the commonly held theories and practices regarding the etiology, diagnosis, and treatment of this common clinical scenario. However, there continues to be a paucity of prospective, randomized trials addressing this topic as it relates to clinical outcomes. We searched PubMed for Englishlanguage articles from 1960 to 2011 using the keywords cocaine, chest pain, coronary arteries, myocardial infarction, emergency department, cardiac biomarkers, electrocardiogram, coronary computed tomography, observation unit, β-blockers, benzodiazepines, nitroglycerin, calcium channel blockers, phentolamine, and cardiomyopathy; including various combinations of these terms. We reviewed the abstracts to confirm relevance, and then full articles were extracted. References from extracted articles were also reviewed for relevant articles. In this review, we critically evaluate the limited historical evidence underlying the current teachings on cocaine's cardiovascular effects and management of cocaine-associated chest pain. We aim to update the reader on more recent, albeit small, studies on the emergency department evaluation and clinical and pharmacologic management of cocaine-associated chest pain. Finally, we summarize recent guidelines and review an algorithm based on the current best evidence. Proc. 2011;86(12):1198-1207 ACS = acute coronary syndrome; AHA = American Heart Association; CCB = calcium channel blockers; CCP = cocaine-associated chest pain; DBP = diastolic blood pressure; ECG = electrocardiography; ED = emergency department; HR = heart rate; MAP = mean arterial pressure; MI = myocardial infarction; PCI = percutaneous coronary intervention; SBP = systolic blood pressure; STEMI = ST-segment elevation myocardial infarction; TIMI = Thrombolysis in Myocardial Infarction E very year millions of Americans abuse cocaine, many of whom present to the emergency department (ED) with cocaine-related complications, most commonly chest pain. Unfortunately, much of the current thinking on cocaine and its cardiovascular effects is either anecdotally derived or based on small studies conducted more than 2 decades ago. Recently, newer studies have brought into question many of the commonly held theories and practices regarding the etiology, diagnosis, and management of cocaine-associated chest pain (CCP) and suspected myocardial ischemia.
Mayo ClinWe searched PubMed for English-language articles from 1960 to 2011 using the keywords cocaine, chest pain, coronary arteries, myocardial infarction, emergency department, card...
