Statement highlights: 

• When treating a patient with chest pain who has no obvious risks of heart disease, doctors should ask if the patient has used cocaine.
• Exposure to cocaine can make clot-busting treatment and beta-blockers dangerous.
• A bare metal stent is preferred over a drug-eluting stent in long-term cocaine users.
• Most cocaine-associated chest pain is not a heart attack. Thus, it is recommended that these patients be monitored in an observation unit for 9 to 12 hours.

DALLAS, March 17 — Doctors treating chest pain in patients who are young or have no obvious risk factors for heart disease should ask the patients about cocaine use. 

That’s a key recommendation in a new American Heart Association scientific statement published in Circulation: Journal of the American Heart Association. 

View Scientific Advisory here

If physicians suspect a heart attack, it’s essential to rule out cocaine use because exposure to the drug could affect what is safe and effective treatment, said James McCord, M.D., chair of the statement writing committee and cardiology director of the chest pain unit for the Henry Ford Medical System in Detroit, Mich. Two standard heart attack treatments — clot-busting drugs and beta-blockers — can be dangerous if someone has been using cocaine. 

Assessing for cocaine use in patients with chest pain but not risk factors is especially important in younger patients, he said. People 35 to 44 years old account for 37 percent of all cocaine-related visits to emergency departments. 

The statement notes cocaine-related emergency department visits increased by 47 percent from 1999 to 2002. Thus, the number of emergency department encounters with patients who have cocaine-associated chest pain will likely increase. 

Studies indicate that chest pain related to cocaine use tends to show up within three hours of using the drug. But the chemical remnants of cocaine remain in the system for at least 18 hours and can continue to cause problems, McCord said. 

Younger patients tend to have findings on their electrocardiogram that make the diagnosis of a heart attack more challenging, McCord said. 

One common way to diagnose and treat certain heart attacks is in a catheterization lab, where doctors thread a tiny tube into the heart’s arteries and use imaging to pinpoint the location of a blockage, and open the artery with a balloon. 

When a cath lab is not available, patients with an apparent heart attack many times receive a clot-busting drug. Clot busters carry extra risk of bleeding into the brain in patients whose blood pressure is high due to recent cocaine use and should be reserved only for patients who are definitely experiencing a heart attack, McCord said. 

Beta-blockers can effectively lower blood pressure without constricting the arteries of typical heart attack patients. But in cocaine users with chest pain, the drugs have the opposite effect: raising blood pressure and squeezing cocaine-narrowed arteries. This has led to seizures and death in some laboratory animals, McCord said. 

In patients who do have a coronary artery blockage, bare metal or drug-eluting stents are often inserted to restore blood flow to the heart. The statement notes that patients with a long history of cocaine use may not be compliant in taking medication to keep drug-eluting stents from becoming blocked. 

Because of that, the statement suggests these patients receive bare metal stents. 

In addition to chest pain and heart attack, studies also link cocaine use to aortic dissection (a potentially fatal blood vessel tear usually found only in older people with a history of high blood pressure) and “crack lung” (bleeding into the lung). 

Cocaine’s effects on the body can make a heart attack worse. The drug increases the heart’s need for oxygen by driving up heart rate, elevating blood pressure and increasing the heart’s contraction (squeezing power) with each beat. At the same time, cocaine deprives the heart of oxygen by constricting the blood vessels and making the blood more likely to clot and cause a heart attack. The chest pain, called angina, is a symptom of the heart being starved for oxygen. 

Other symptoms reported by patients with cocaine-related chest pain include shortness of breath, anxiety, palpitations, dizziness, nausea and profuse sweating. All of those are also symptoms of a heart attack. 

Most cocaine-associated chest pain is not a heart attack. Studies report actual heart attack rates of between 0.7 percent to 6 percent for patients who seek emergency treatment of cocaine-associated chest pain. Still, because heart attacks are less common in people under age 45, cocaine appears to be an important contributor to heart attacks in the young, the statement says. 

Patients with chest pain due to cocaine use have a lower risk of heart attack than the typical older heart patient. For that reason the statement recommends that, instead of being admitted to the hospital, these patients be sent to an observation unit where their vital signs can be monitored. 

“If the patients are alert and can talk to you, typically you want to tell them, ‘Look, it is important for us to know if you are taking cocaine because it could change the way we treat you,’” McCord said. “If a patient is unconscious, a drug test could be done at the physician’s discretion.”

Healthcare providers have an opportunity to offer drug cessation counseling when they send patients to an observation unit, McCord said. 

“Currently, the level of drug counseling available in most observation units, particularly at night, usually amounts to a pamphlet on drug abuse and referral phone numbers,” he said. “This is an area where we can do a better job.” 

“We should try to use that hospital visit as a teachable moment to educate these patients on how they can improve their health and offer them counseling and referral to programs for drug cessation.” 

Co-authors include: Bojan Cercek, M.D.; James A. deLemos, M.D.; Barbara Drew, R.N., Ph.D.; W. Brian Gibler, M.D.; Judd E. Hollander, M.D.; Priscilla Hsue, M.D.; Hani Jneid, M.D.; L. Kristin Newby, M.D.; E. Magnus Ohman, M.D.; and George Philippides, M.D. 

Disclosures: McCord: Biosite, Diagenics, Inovise, Itamar (research grants), Biosite (speakers bureau/honoraria).

NR08-1042 (CIRC/McCord)