This handout is for cocaine-induced atrial flutter (sympathetic + α-adrenergic + na-channel substrate). Your care team identified this based on: recent cocaine / sympathomimetic use (within 1–24 h) presenting with new atrial flutter on 12-lead ecg (aha 2008 pmid 18391116).
Other reasons your team may use this plan: atrial flutter on ecg + positive urine drug screen for cocaine / amphetamine metabolites (benzoylecgonine detectable 2–4 d post-use); hypertension + tachycardia + agitation + diaphoresis + palpitations after cocaine use with afl pattern — sympathomimetic α-adrenergic crisis with atrial arrhythmia; chronic cocaine user (>1 yr) with recurrent afl — accelerated atrial substrate from repeated arrhythmogenic stimulation (hsue circulation 2002 pmid 12473532).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| lorazepam | 1–2 mg IV | IV | q5–15 min PRN sympathetic crisis | AHA 2008 Class I (PMID 18391116) — benzo breaks sympathetic crisis, reduces myocardial oxygen demand and BP, often reduces RVR through sympatholytic effect; first-line in cocaine arrhythmia |
| nitroglycerin | 0.4 mg SL q5 min × 3 → IV 5–200 mcg/min if persistent HTN or chest pain | SL/IV | continuous IV titrate to BP and pain | AHA 2008 Class I — reverses cocaine-induced coronary vasoconstriction + reduces afterload; preferred over BB acutely |
| phentolamine | 1–5 mg IV q5–15 min | IV | PRN refractory HTN | AHA 2008 Class IIa — selective α-block reverses cocaine-induced vasoconstriction without unopposed-α paradox; reverses inadvertent BB-cocaine interaction (Lange NEJM 1989 PMID 2522592) |
| diltiazem | 0.25 mg/kg IV bolus → 5–15 mg/h infusion; 120–360 mg/day PO | IV/PO | IV bolus + infusion → PO daily | AHA 2008 + ACC/AHA 2025 — non-DHP CCB PREFERRED over β-blocker in cocaine context (no unopposed-α paradox); AVN slowing for AFL rate control; AVOID in HFrEF or hypotension |
| verapamil | 5–10 mg IV slowly OR 80–120 mg PO TID | IV/PO | IV / PO | Alternative non-DHP CCB; AVOID in HFrEF — AHA 2008 + ACC/AHA 2024 (PMID 38753446) |
| synchronized_DCCV_100J_biphasic | 100 J synchronized biphasic; escalate to 200 J if unsuccessful | electrical | single shock; may repeat at higher energy | ACC/AHA 2024 Class I (PMID 38753446); flutter cardioverts at low energies; first ensure cocaine-related hyperadrenergic state is treated to reduce post-CV recurrence + replete K + Mg |
| amiodarone | 150 mg IV over 10 min then 1 mg/min × 6 h then 0.5 mg/min × 18 h; 200 mg PO daily maintenance | IV/PO | load + daily | Acceptable in cocaine context (no β-blocker paradox); minimal pure β-blockade effect; pulm/thyroid/hepatic toxicity with chronic use — ACC/AHA 2024 (PMID 38753446) |
| apixaban | 5 mg BID (2.5 mg if 2 of: ≥80 yr, ≤60 kg, Cr ≥1.5) | PO | BID | ARISTOTLE (Granger NEJM 2011 PMID 21870978) — preferred DOAC; ACC/AHA 2024 Class I; counseling on adherence critical in cocaine substrate |
| rivaroxaban | 20 mg with food (15 mg if CrCl 15–50) | PO | once daily | ROCKET-AF (PMID 21830957); X-VeRT data extends to flutter — ACC/AHA 2024 |
| warfarin | INR target 2–3 | PO | daily | Mechanical valve / severe MS only; INR monitoring may be unreliable in non-adherent cocaine users — ACC/AHA 2024 (PMID 38753446) |
Plan: Cocaine-induced atrial flutter — benzo first + diltiazem-preferred rate control + DCCV if unstable + standard AC + AVOID β-blocker monotherapy + cessation mandatory — AHA 2008 (PMID 18391116) + ACC/AHA 2024 (PMID 38753446) + ACC/AHA 2025 ACS
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
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
Guideline: 2024 ACC/AHA/ACCP/HRS AF + AFL Joint Guideline (Joglar PMID 38753446) + AHA 2008 Cocaine cardiovascular complications (McCord PMID 18391116) + 2025 ACC/AHA ACS Guideline