Cocaine Associated Chest Pain & AMI


Cocaine is a powerful sympathomimetic and ⇑O2 demand:

  • Blocking re-uptake of norepinephrine and dopamine at the pre-synaptic adrenergic terminals
  • Cocaine causes ↑HR and ↑BP in a dose-dependent fashion

The chronotropic effects of cocaine are intensified in the setting of alcohol use.

Cocaine ↓left ventricular function and increase end-systolic wall stress.

By ↑ HR, BP, and contractility, cocaine leads to ↑ myocardial demand.

Cocaine is a potent coronary vasoconstrictor:

  • Vasoconstriction worse with pre-existing CAD - particularly smokers
  • Direct coronary art wall myocyte adrenergic stimulation
  • Cocaine ↑ levels of endothelin-1 (a powerful vasoconstrictor) and ↓ nitric oxide (vasodilator)

Cocaine is pro-thrombotic:

  • It ↑ platelet count, activation and platelet hyper-aggregability


  • Aspirin & nitrates are strongly recommended
  • β-blockers are contraindicated (may induce or worsen ⇑BP and vaso-spasm
  • Benzodiazepines are recommended as the primary treatment for anxiety, tachycardia, and hypertension
  • Calcium channel blockers are not recommended
  • Early PCI is particularly preferred over fibrinolysis in patients with cocaine-associated MI:
    • ↑ risk for intracranial haemorrhage after fibrinolytic agents in cocaine users

Clinical presentation

  • Chest pain (often "cardiac sounding") is the commonest (56%) presenting complaint amongst cocaine users
  • Dyspnoea and shortness of breath are commonly associated
  • Beware - up to half of cocaine associated AMIs do NOT report chest pain (palpitations or SOB etc)
  • Cocaine associated chest pain may be due to aortic dissection, pneumothorax or pneumomediastinum
  • General features of cocaine intoxication

Investigations / Management


  • An abnormal ECG has been reported in 56% to 84% of patients with cocaine-associated chest pain
  • ECG sensitivity in revealing ischaemia or MI to predict a true MI is only 36%
  • Specificity, positive predictive value, and negative predictive value of the ECG are 89.9%, 17.9%, and 95.8%, respectively

Cardiac Biomarkers

  • Cocaine may cause rhabdomyolysis (raised myoglobin and total CK in up to 75% of patients)
  • Cardiac troponins are the most sensitive and specific markers

General and other features of cocaine intoxication


  • As only 0.7% to 6% of patients with cocaine-associated chest pain progress to an AMI, risk stratification of these patients in the CDU may be appropriate
  • High risk patients or those with positive ECG / markers should be admitted to CCU
  • Low risk patients with normal initial Ix should be transferred to the CDU
  • Exercise Stress Testing is an unusual option (decision by emergency medicine consultant) for patients with cocaine-associated chest pain who have had an uneventful 9 to 12 hours of observation. (Ref)

Content by Dr Íomhar O' Sullivan based on AHA 2008 guidelines. Last review 11/04/23.