Coronary spasm after the topical use of cocaine in nasal surgery

Abstract

SummaryBackground:Cocaine is a frequently used recreational drug which imposes important health problems with even life-threatening cardiotoxicity. The therapeutic use of cocaine is nowadays restricted to topical anesthesia in ophthalmological and nasal surgery but the possible hazards of this local anesthesia are not always fully appreciated.Case Report:A 51-year old male patient with moderate cardiovascular risk profile underwent elective nasal surgery and cocaine was used as a local anesthetic. During surgery, ventricular arrhythmias and cardiogenic shock occurred, mimicking an ST-segment elevation myocardial infarction (STEMI) in sinus rhythm. Coronary angiography showed diffuse spasm of the right coronary artery (RCA) which disappeared with intracoronary nitrates. Urine analysis was positive for cocaine. The patient recovered completely with a normal echocardiography and ECG at discharge.Conclusions:Cocaine cardiotoxicity is not uncommon in the community but a particular situation arises when used in medicine as a topical anesthetic. This is the first case report, to our knowledge, of a cardiogenic shock mimicking a STEMI with documentation of diffuse coronary spasm after cocaine use in nasal surgery. One must be aware of the potential life-threatening complications in this low-risk surgery, moreover when safer alternatives are available.

Chest pain in the recovery room, following topical intranasal cocaine solution use

“…It causes a severe sympathomimetic response, primarily by inhibiting norepinephrine, serotonin and dopamine, at sympathetic preganglionic nerve endings 5. Cocaine also causes the release of epinephrine and norepinephrine from the adrenal medulla 9.…”

“…Increased adrenergic activity increases myocardial rate, arterial pressure and ventricular contractility, and therefore oxygen demand, while conversely there is widespread vasoconstriction and reduced oxygen delivery 9. Coronary vasoconstriction is thought to be secondary to increased production of endothelin and decreased production of nitrous oxide 5. With a greater risk of focal occlusive vasospasm, there is also a prothrombotic state.…”

“…With a greater risk of focal occlusive vasospasm, there is also a prothrombotic state. Increased platelet activity and aggregation occurs, and intranasal administration is also associated with an increase in plasma plasminogen activator inhibitor 5 9…”

“…This mechanism can also impair cardiac impulse conduction and generate ventricular arrhythmias 5. Cocaine also prolongs the QT interval by inhibiting myocyte repolarisation 9.…”

“…Several alternatives to cocaine have been proposed, including local anaesthetic combinations, and have shown to be equally efficacious with a lower cardiac risk profile 5 6…”