A young, fit looking 22 year old man presents to the Triage desk at 2am on a Saturday morning. He is restless and anxious and complaining of some vague chest discomfort. The pain started whilst he was out at a local nightclub with friends.
Despite the fact he is worried, he doesn’t look too bad and you are wondering if he is just having an ‘anxiety attack’.
His pulse is 102 and his resps 20, other observations are unremarkable.
He is a smoker, but has no family history of heart problems and has no medical conditions.
He denies any drug use stating that he has “just had a couple of beers” during dinner.
What do you think?
Should we be concerned about this young man. Is he just one of the worried well? Surely he couldn’t be having an infarct?

Cocaine hydrochloride:

Coke, crack, C, snow, cola, blow, toot, leaf, flake, freeze, nose candy or white dust.
Cost in Australia, around $300-$400 per gram.
A stimulant derived from the leaves of the coca plant, cocaine is becoming the drug of choice for the middle class.

In Australia, the Australian Crime Commission’s (ACC) 2008-2009 Illicit Drug Data Report, suggested a rise in our cocaine market with the drug moving from the domain of the wealthy and famous to a growing number of lower socio-economic users. There was a jump of 27% in cocaine related arrests between 2007 and 2008.
Many social users of coke see it as a more benign way to get high than many other hard drugs such as heroin. They do so at their peril, underestimating its psychological dependence, rebound ‘downs’, paranoia, and potential cardiac effects.

Cocaine comes in four main forms:

  • Cocaine hydrochloride (powder): The most common form of cocaine is as a salt – as cocaine hydrochloride. This is a white powder with a bitter, numbing taste. Cocaine hydrochloride cannot be smoked effectively because the drug is destroyed at high temperatures.
  • Freebase: By moving the hydrochloride through a chemical process the drug is converted into ‘freebase’ which can then be smoked. Freebase is a white, off-white or pinkish powder.
  • Crack: Crack is a particularly pure form of freebase cocaine. It takes the form of small lumps or rocks. The colour of crack depends on a range of factors, including the origin of the cocaine, the way it is produced and its impurities. It usually ranges from white to light brown. The name crack comes from the crackling sound made when cocaine with impurities is heated. Crack is less commonly used in Australia.
  • Leaf: Leaves from the coca plant are used to make an herbal infusion tea. Compared to other forms, the effects are much milder than other forms and does not produce the numbing and rush. Cocaine is generally only used in this way in South America.

:: Cocaine Basics ::

Effects on the heart:

Cocaine is absorbed from the gastrointestinal and respiratory tract. Its effects peak in between 1 and 90 minutes depending on the route of ingestion.
Cocaine causes tachycardia and increased oxygen demand a situation that is exacerbated when alcohol is taken at the same time. It also causes vasoconstriction, including constriction of the coronary arteries. This occurs even when only small doses are taken ( for example, via the nasal route).
Continued use can lead to hypertension, thrombogenicity (increased clotting of the blood) and atherosclerosis. This is a potent combination of effects that predispose the myocardium to ischaemia. Cocaine has also been associated with dissection of the coronary arteries which can really spoil your day.

People using Cocaine usually develop chest pain around 3 hours after using. The pain is often atypical in character and duration although it may be described as a pressure like in quality, and it can be accompanied by anxiety, palpitations, nausea and shortness of breath.
Symptoms may persist for up to 4 days after use.

Presentations to hospital:

A recent study in the emergency medicine journal found a significant proportion of patients attending emergency departments in the UK with chest pain may have used Cocaine. Especially young adults presenting on weekends or in the evenings.
Of the 144 who were diagnosed as having acute coronary syndrome, 6 tested positive for cocaine and of those six, two (36 and 42 years old) went on to have a diagnosis of myocardial infarction.
Other studies in the US have shown the prevalence of cocaine use in patients presenting with chest pain to be as high as 17%. And a study in Spain showed 13.3% use of cocaine in patients presenting with trauma or chest pain.
Interestingly, of all the patients included in the UK study who presented with chest pain, only 18% had a specific drug history recorded in their medical notes.

Bottom line:

Not only is it important to flag cocaine related chest pain as having the potential to lead to myocardial injury or infarction, but the management of cocaine induced chest pain is a little different form the usual chest-pain pathway1.

And with the probability that this group of people presenting with chest pain may be young, relatively healthy and reluctant to disclose their drug history, medical staff should be vigilant to the use of cocaine as a possible cause.

References:

  1. Cocaine: Middle Class High (TIme Magazine)
  2. Prevalence of cocaine use among patients attending the emergency department with chest pain (Emerg Med J 2010 27: 548-550)
  3. Management of Cocaine-Associated Chest Pain and Myocardial Infarction (Circulation)
  1. Benzodiazepines are included as a first line treatment and the use of beta-blockers may be contraindicated. []

4 Responses to “cocaine use and chest pain.”

  1. Cocaine use and MI’s……great information! I work in an ER in New Jersey, USA. Often times when a young individual with chest pain comes to the ER it is assummed to be non-cardiac. We do EKG’s within 5 minutes on all chest pains (no matter what age). Are most of the cocaine-induced MI’s ST elevated??

  2. Great post Ian, don’t see much cocaine use in WA. The two cases I have seen in WA have been from east coast travellers. Keep the posts coming.

  3. This is a great reminder of a tip I was given as a student nurse in the ED as an extra pair of hands- do an ECG on people who do not fit the ‘picture’ for evolving cardiac events, you have lost nothing if there is nothing to show and you have been able to practice your ECG taking. It worked when I was a student in Sydney as it really happened, so lesson learnt

  4. I’ve had a few patients present with aortic dissections that were in their 30′s and the only identifiable trigger was cocaine use. One of them ended up with a small intramural haematoma that eventually resolved, the other ended up needing replacement of their ascending aorta. Idiots.

Leave a Reply

(required)

(required)

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>

  • impactednurse.com will soon be gone. (3)
    • Zeke said: Are you keeping an archive of this site on the nurse path site?

    • jelly said: Just work a few more hundred Sundays!

    • matgrad said: Bye Ian will miss the site but as you say everything has its day. Good luck for the future.

  • Nurses are F*cking C*nts. Verbal abuse in our workplace. (32)
    • Rose said: I have read this article and found it very relevant to me and my own experience.Unfortunately a lot of people think that it is quite OK and acceptable to take out their anger and frustration against a sometimes inadequate health system on nursing staff. I also think that gender is an issue as I often feel that female nurses are...

  • Nominate Now: Social Media Nurse of the Year. (21)
    • Belynda Abbott said: I would like to nominate 3 amazing nurses that contribute to nursing and social media in many different ways: 1. The amazing Philip Darbyshire @PDarbyshire and http://www.philipdarbyshire.co m.au/index.php?option=com_easy blog&view=entry&id=44& amp;Itemid=13&utm_source=b uffer&utm_campaign=Buff...

  • When a patient leaves with cannula in-situ. (17)
    • Andy said: Good thinking! At my hospital the Oncology staff are trained/instructed to bleed CVADs before every use regardless, to remove potential clots, discard, flush, then use. Another excuse if you need it ;)

  • bully nurse. (40)
    • G Boucle said: This is not surprising at all to me! Nurses can and do bully patients, I was on the brunt of this after a surgery with spinal fusion on 5 segments! The pain was blinding, they bickered in front of me over who would change the cath bag on the floor already filled and looking about to burst, I found this extremely upsetting....

  • The art of bleeding. Art, insult…or just plain WTF? (6)
    • Contrarian said: I have seen at least one, maybe two live performances of the Art of Bleeding (they were performing at the periphery of other attention-immersive events). Of course the nurse-slut costume is a standard image, but they turn it on its head and dissect it. So, yes, as they say, while the nurse slut draws in the viewer, the viewer is...