Written by: Maren Leibowitz, MD (NUEM ‘23) Edited by: Zach Schmitz, MD (NUEM ‘21) Expert Commentary by: David Farman, MD
Expert Commentary
Cocaine chest pain was something that was frequently discussed but rarely encountered during my training and during my 11 years practicing in suburban and metropolitan Indiana (we're more of a heroin/meth state). I suspect there is significant regional and local variation in the epidemiology of cocaine chest pain, likely influenced by the economics and local availability or popularity of intoxicants.
When cocaine is more expensive, we tend to see more methamphetamine use. And vice-versa. I was once told by a local sheriff that "people will get high on whatever they can get for less than $20" and I have found that to be true in practice. I wouldn't expect that an emergency physician would be intimately familiar with the local micro-economics of the drug trade, but one should expect there to be a periodic waxing/waning of cocaine chest pain presentations. Similarly, it may be a more frequent complaint dependent on cocaine's local popularity and availability.
When consulting with a Cardiologist about a cocaine chest pain case, it is important for the emergency physician to avoid letting premature closure or psychosocial biases unduly influence the patient's disposition. It is not unheard of for physicians to minimize objective findings (ST segment abnormalities or biomarker elevation) and attribute them to the vasoactive properties of cocaine. I have certainly been tempted to do so myself. However, the article wisely points out the physiologic changes induced by cocaine use, both acutely and chronically. Platelet aggregation and atherogenesis can absolutely promote a scenario that would require PCI in even the most frequent of 'frequent fliers' with cocaine chest pain.
In short, I would have a low threshold to involve Cardiology in a patient who has objective findings regardless of their use of cocaine. Similarly, a Cardiology request for a Urine Drug Screen shouldn't delay a patient's trip to the cath lab if they have a STEMI. An exception to this may be a patient who has had recent coronary angiography that objectively demonstrates normal coronaries. In that scenario I would consider serial markers, conservative management and strong consideration of non-cardiac causes of the pain (dissection, pneumothorax, etc.).
David Farman, MD FACEP
Emergency Medicine Physician
Franciscan Health Lafayette East
How To Cite This Post:
[Peer-Reviewed, Web Publication] Leibowitz, M. Schmitz, Z. (2021, May 10). Cocaine Chest Paine. [NUEM Blog. Expert Commentary by Farman, D]. Retrieved from http://www.nuemblog.com/blog/cocaine-chest-pain
