Dallas, TX - People admitted to the hospital with chest pain or MI associated with cocaine use should be treated much the same as any other patient with "traditional" ACS, but with the addition of intravenous benzodiazepines and a cautionary approach to beta blockers, a new American Heart Association (AHA) statement recommends. According to the writing group, led by Dr Jim McCord (Henry Ford Hospital, Detroit, MI), benzodiazepines relieve chest pain and have beneficial cardiac hemodynamic effects; they are a class 1 recommendation in the statement, with a B level of evidence.

McCord et al write that cocaine accounts for more than 100 000 emergency-department visits in the US each year, with chest pain being one of the most common complaints. The authors also point out that cocaine-related emergency-department visits rose by almost 50% between 1999 and 2002, suggesting that the number of people coming to the emergency room with cocaine-associated chest pain "will likely be increasing."

Cocaine has multiple effects on the heart, including driving up blood pressure, heart rate, and contractility, the authors note. It also has vasoconstrictive effects on the coronary arteries and is associated with increased platelet count, increased platelet activation, and platelet hyperaggregability.

While the full pathological effects of cocaine are unknown, researchers believe cocaine-induced MI appears to occur soon after ingestion, usually within the first few hours, although other studies suggest that, particularly in chronic users, ischemia can occur many hours or even days after cocaine use. In their statement, the AHA writing group emphasizes that self-reporting should be the primary means of establishing a role for cocaine use in a chest-pain patient, but that, given the reluctance to admit to cocaine use, urine tests may sometimes be necessary.

McCord et al also suggest that the evaluation and management of a patient with cocaine-induced chest pain or MI should be similar to the approach recommended in someone with no history of cocaine use, with the important exception of adding benzodiazepines. Evidence also suggests that beta blockers should be avoided in the acute phase, given the propensity of some of these agents to worsen coronary artery vasoconstriction and increase blood pressure. Indeed, given the high number of cocaine users who continue to use the drug even after an MI, physicians may need to avoid beta blockers even for the long-term management of patients with coronary artery disease.

For this reason and others, McCord and colleagues emphasize that cessation of cocaine use "should be the primary goal of secondary prevention."