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cardio.atrial_flutter.cocaine-related.v1

Cocaine-induced atrial flutter (sympathetic + α-adrenergic + Na-channel substrate)

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Phase E variant of cardio.atrial_flutter.v1 — cocaine-induced atrial flutter with sympathetic + α-adrenergic + Na-channel substrate. Inherits AC + acute rate/rhythm management from parent; specializes for benzo-first pathway (AHA 2008 Class I PMID 18391116 — lorazepam 1–2 mg IV breaks sympathetic crisis), diltiazem-preferred rate control (ACC/AHA 2025 ACS Class III against β-blocker monotherapy in cocaine context per Lange NEJM 1989 PMID 2522592 unopposed-α paradox), mandatory aortic dissection rule-out before AC (cocaine doubles dissection risk per IRAD), and concurrent ACS exclusion via troponin + ECG with routing to dedicated cocaine-induced ACS variants. Cocaine cessation is the dominant long-term mortality lever (Hollander NEJM 2008); addiction medicine consult mandatory; AC adherence counseling critical given recidivism; LAA occlusion (Watchman) considered if persistent active use precludes safe long-term DOAC. AVOID flecainide / propafenone (additive Na-channel blockade with cocaine); amiodarone acceptable for refractory rhythm strategy. Carvedilol or metoprolol may be initiated AFTER ≥1 week cocaine-free if HFrEF substrate per AHA 2008; mixed α/β agent (carvedilol) preferred over pure β1 blocker. Manifest pointer reuses cardio.atrial_flutter.v1 manifest. Design-brief pointer reuses parent. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute.

Entry points (4)

  • history
    Recent cocaine / sympathomimetic use (within 1–24 h) presenting with new atrial flutter on 12-lead ECG (AHA 2008 PMID 18391116)
    recent_cocaine_use_with_aflutter_on_ecg
  • imaging
    Atrial flutter on ECG + positive urine drug screen for cocaine / amphetamine metabolites (benzoylecgonine detectable 2–4 d post-use)
    aflutter_with_positive_uds_cocaine
  • symptom
    Hypertension + tachycardia + agitation + diaphoresis + palpitations after cocaine use with AFL pattern — sympathomimetic α-adrenergic crisis with atrial arrhythmia
    sympathetic_crisis_with_palpitations_and_aflutter
  • history
    Chronic cocaine user (>1 yr) with recurrent AFL — accelerated atrial substrate from repeated arrhythmogenic stimulation (Hsue Circulation 2002 PMID 12473532)
    chronic_cocaine_user_with_recurrent_aflutter

Required inputs (18)

  • agerequired
    demographic • used at CONTEXT
    Cocaine-related AFL commoner age 25–55; younger than typical type-1 AFL substrate; informs differential weighting + bleed-risk balance
  • sbprequired
    vital • used at RED_FLAGS
    Sympathetic crisis SBP often >180; gates phentolamine + nitroglycerin; hypotension + AFL = SCAI B-C cardiogenic-shock screen + emergent CV; rule out aortic dissection if discordant arm BPs (cocaine doubles dissection risk per IRAD)
  • hrrequired
    vital • used at CONTEXT
    AFL with RVR HR 130–180+ typical; sinus tachycardia from sympathetic surge often coexists; QRS widening warns of Na-channel blockade requiring NaHCO3 (workup.cocaine_chest_pain)
  • temprequired
    vital • used at RED_FLAGS
    Hyperthermia >39 + agitation = severe cocaine toxicity → aggressive cooling + benzodiazepine (NOT antipsychotic per AHA 2008)
  • urine_drug_screenrequired
    lab • used at INITIAL_WORKUP
    Confirms cocaine / amphetamine exposure; benzoylecgonine detectable 2–4 d post-use; informs disposition + substance use disorder treatment referral
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Troponin elevation common with cocaine — distinguishes concurrent ACS (cocaine-induced MI) from isolated AFL with demand ischemia from RVR; gates acs_pathway routing
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    Rhabdomyolysis common with cocaine + agitation → AKI; influences AC dosing + DOAC dose selection per KDIGO 2026
  • cpk_myoglobinrequired
    lab • used at INITIAL_WORKUP
    Rhabdomyolysis screen — common with cocaine + agitation + restraint; gates aggressive IVF
  • bmp_mg_krequired
    lab • used at INITIAL_WORKUP
    K+ ≥4 and Mg ≥2 mandatory before any DCCV or AAD; cocaine + diuretic effect or rhabdo can deplete
  • tsh
    lab • used at INITIAL_WORKUP
    Reversible cause screen (thyrotoxic flutter); cocaine may unmask occult hyperthyroidism via sympathetic potentiation
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    Confirm AFL morphology; rule out STEMI mimic (cocaine vasospasm); assess QRS width (Na-channel blockade) + QTc baseline before any AAD
  • cxrrequired
    imaging • used at INITIAL_WORKUP
    Aortic dissection screen (mandatory in cocaine context per AHA 2008); pulmonary edema; PTX from valsalva or "crack lung"
  • cta_chest_if_dissection_concern
    imaging • used at RED_FLAGS
    CT-A chest if any concern for aortic dissection (cocaine doubles dissection risk per Eagle IRAD); MUST rule out before heparin or AC for AFL
  • tterequired
    imaging • used at INITIAL_WORKUP
    Bedside echo: LVEF, valvular function, LA size, thrombus screen, pre-existing cocaine cardiomyopathy assessment in chronic users
  • cha2ds2_vasc_factorsrequired
    history • used at RISK_STRATIFICATION
    AFL stroke risk identical to AF; in cocaine substrate counseling on AC adherence is critical given recidivism; LAA occlusion candidacy if persistent active use
  • bleeding_historyrequired
    history • used at RISK_STRATIFICATION
    HAS-BLED elevated in cocaine users (uncontrolled HTN + alcohol + polypharmacy + injection sites); AC bleed-risk balance
  • pattern_chronic_vs_recent_cocaine_userequired
    history • used at CONTEXT
    Chronic users (Hsue 2002 PMID 12473532) have accelerated atrial substrate → higher recurrence + ablation candidacy; first-time use → reversible cause if cessation achieved
  • co_ingestantsrequired
    history • used at CONTEXT
    Alcohol → cocaethylene (more cardiotoxic + arrhythmogenic); benzo / opioid co-use changes sedation strategy + intentionality screen

12-phase flow (12)

  1. 1FRAME
    Confirm cocaine-related AFL per AHA 2008 PMID 18391116 — distinguish sympathetic-crisis-driven AFL vs concurrent ACS-induced AFL vs accelerated atrial-substrate AFL in chronic users; rule out aortic dissection FIRST (AHA 2008 mandatory before heparin or AC)
    inputs: ecg_12_lead, urine_drug_screen
    advance: cocaine etiology confirmed + dissection excluded
  2. 2ENTRY
    AFL on ECG + recent cocaine use or positive UDS → benzo-first pathway for sympathetic crisis; concurrent bedside echo + ACS workup; coordinate with cardiology + critical care if hemodynamically unstable
    inputs: age
    actions: cocaine_chest_pain
    advance: engine entered + benzo-first pathway initiated
  3. 3CONTEXT
    Recent vs chronic use, co-ingestants (alcohol → cocaethylene), prior ACS, prior AFL, OAC use, mental health / substance use disorder context, intentionality (overdose vs recreational)
    inputs: hr, creatinine_egfr, pattern_chronic_vs_recent_cocaine_use, co_ingestants
    advance: context complete
  4. 4RED_FLAGS
    Aortic dissection (mandatory rule-out before heparin/AC per AHA 2008); cardiogenic shock SCAI C+ from concurrent ACS or massive AFL RVR (DanGer Shock PMID 38587234 routing); QRS widening → NaHCO3; hyperthermia + agitation → aggressive cooling + benzo (NOT haloperidol); sustained VT/VF (AVOID procainamide — Na-block additive)
    inputs: sbp, temp
    actions: chest_pain, cocaine_chest_pain, cardiogenic_shock
    advance: dissection ruled out + sympathetic crisis controlled + shock screened
  5. 5INITIAL_WORKUP
    Serial ECG q15 min × 1 h; troponin (rule out concurrent MI); BMP, CBC, UDS, CPK / myoglobin (rhabdo), lactate, TSH, CXR (mandatory dissection screen), bedside echo (LVEF + valvular + LA size + cocaine cardiomyopathy)
    inputs: ecg_12_lead, troponin, urine_drug_screen, cpk_myoglobin, cxr, creatinine_egfr, bmp_mg_k, tte
    actions: acs_pathway, cocaine_chest_pain, panel.cardiac, panel.renal
    advance: workup complete + dissection excluded + ACS triaged
  6. 6BRANCHING_WORKUP
    If concurrent ACS (positive troponin + symptoms + ECG changes) → acs_pathway routing to cardio.nstemi.cocaine-induced.v1 or cardio.stemi.cocaine-induced.v1; TEE pre-CV if cardioversion delayed beyond 48 h without therapeutic AC; concomitant AF detection → cardio.afib.core.v1 routing
    actions: afib_new_onset
    advance: branch resolved
  7. 7DIFFERENTIAL
    Cocaine-induced AFL (acute sympathetic) vs cocaine-induced AFL with concurrent ACS vs cocaine-cardiomyopathy AFL (chronic substrate) vs aortic dissection presenting as palpitations vs thyrotoxic flutter unmasked by cocaine
    advance: primary substrate identified
  8. 8RISK_STRATIFICATION
    CHA2DS2-VASc for AFL stroke risk; HAS-BLED for AC bleed risk (elevated in cocaine users); CKD-EPI 2021 for DOAC dosing; SCAI staging if shock present
    inputs: cha2ds2_vasc_factors, bleeding_history
    actions: calc.cha2ds2vasc, calc.has_bled, calc.ckd_epi_2021
    advance: risk tier documented
  9. 9TREATMENT
    BENZODIAZEPINE FIRST (lorazepam 1–2 mg IV) for sympathetic crisis (AHA 2008 Class I — breaks BP + HR + arrhythmogenic substrate); DILTIAZEM PREFERRED over β-blocker for rate control (AHA 2008 + ACC/AHA 2025 ACS Class III for β-blocker monotherapy in cocaine context); nitroglycerin for HTN + ischemia; phentolamine for refractory HTN; synchronized DCCV at 100J biphasic if hemodynamically unstable; AC per CHA2DS2-VASc — apixaban first-line; AVOID flecainide / propafenone (additive Na-channel blockade with cocaine); amiodarone acceptable for refractory; mandatory cocaine cessation counseling
    inputs: sbp, creatinine_egfr, bmp_mg_k
    actions: cocaine_chest_pain
    advance: sympathetic crisis broken + AFL rate-controlled or cardioverted + AC initiated + cessation counseling delivered
  10. 10DISPOSITION
    CICU mandatory if hemodynamically unstable or concurrent ACS; floor admission for substance use disorder evaluation + AAD initiation if needed; coordinate with addiction medicine + EP if ablation pathway entered
    advance: disposition + level-of-care set
  11. 11MONITORING
    Continuous ECG; repeat troponin to peak if elevated; BP q15 min until <160; CPK q6 h × 24 h if rhabdo; bleed signs per BARC 2011; QTc daily on AAD; sedation cadence titration
    inputs: ecg_12_lead
    actions: panel.cardiac, panel.renal
    advance: monitoring orders documented
  12. 12FOLLOWUP
    COCAINE CESSATION counseling MANDATORY + warm handoff to substance use disorder treatment (mortality lever per Hollander NEJM 2008); cardiology follow-up week 1 + month 1; EP for CTI ablation if recurrent typical AFL; cardiac rehab; AC adherence review + LAA occlusion candidacy if persistent active use; AVOID β-blocker initiation if continued cocaine use — use diltiazem or non-pharmacologic rate control instead
    advance: substance use disorder referral + cardiology follow-up booked + AC plan with adherence support