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cardio.nstemi.cocaine-induced.v1

Cocaine-induced NSTEMI (sympathetic crisis + vasospasm)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.nstemi.core.v1 — narrowed to cocaine-induced NSTEMI per AHA 2008 PMID 18391116 + ACC/AHA 2025 ACS. Pivots from universal NSTE-ACS bundle by giving benzodiazepine FIRST (lorazepam 1–2 mg IV) for sympathetic crisis, then nitroglycerin + phentolamine for HTN/vasospasm; CCB acceptable; β-blocker monotherapy is AVOIDED acutely (Class III) — Lange NEJM 1989 PMID 2522592 propranolol-cocaine paradox. Inherits parent universal antiplatelet + parenteral AC + statin axes via routing through cardio.nstemi.core.v1 and through workup.cocaine_chest_pain (AHA 2008 protocol). Specialises for cocaine-specific acute pharmacology, mandatory aortic dissection rule-out, rhabdomyolysis screen, and substance use disorder treatment pathway. Long-term: cocaine cessation is the dominant mortality lever (Hollander NEJM 2008). Mixed α/β carvedilol acceptable AFTER cocaine-free ≥1 wk for post-MI HFrEF; pure β-blocker monotherapy avoided indefinitely if relapse risk persists. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute as Phase E wave 9 etiology variant.

Entry points (5)

  • history
    Recent cocaine or sympathomimetic use (within 1–24 h) presenting with ischemic chest pain (AHA 2008 PMID 18391116)
    recent_cocaine_use_with_chest_pain
  • lab_abnormality
    hsTn rise/fall + positive urine drug screen for cocaine / amphetamine metabolites — confirm cocaine-related NSTEMI
    hstn_rise_with_positive_uds_cocaine
  • symptom
    Hypertension + tachycardia + agitation + diaphoresis + chest pain after cocaine use — sympathomimetic α-adrenergic crisis pattern
    sympathetic_crisis_with_chest_pain
  • imaging
    Dynamic ST depression or transient ST elevation in patient with documented cocaine use — vasospasm vs thrombosis
    dynamic_ecg_after_cocaine
  • history
    Chronic cocaine user (>1 yr) with NSTE-ACS pattern — accelerated atherosclerosis substrate (Hsue Circulation 2002 PMID 12473532)
    chronic_cocaine_user_with_acs_pattern

Required inputs (14)

  • agerequired
    demographic • used at CONTEXT
    Cocaine NSTEMI commoner age 30–55; younger than typical type-1 NSTE-ACS; informs differential weighting
  • sbprequired
    vital • used at RED_FLAGS
    Sympathetic crisis SBP often >180; gates phentolamine + nitroglycerin therapy; rule out aortic dissection if discordant arm BPs
  • hrrequired
    vital • used at CONTEXT
    Sinus tachycardia >120 typical; 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)
  • urine_drug_screenrequired
    lab • used at INITIAL_WORKUP
    Confirms cocaine / amphetamine exposure; benzoylecgonine detectable 2–4 d post-use; informs disposition and substance-use treatment referral
  • hs_troponin_serialrequired
    lab • used at INITIAL_WORKUP
    0/1-h or 0/3-h ESC 2023 algorithm — defines NSTEMI vs UA; many cocaine chest-pain presentations have flat troponin and resolve with benzo + nitrates alone
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    Rhabdomyolysis common with cocaine + agitation → AKI; influences contrast / AC dosing
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Baseline before AC; rule out concomitant infection (endocarditis from IV cocaine use)
  • cpk_myoglobinrequired
    lab • used at INITIAL_WORKUP
    Rhabdomyolysis screen — common with cocaine + agitation + restraint; gates aggressive IVF
  • ecg_serialrequired
    imaging • used at INITIAL_WORKUP
    Dynamic ECG q15 min × 1 h; QRS widening (Na-channel blockade) → NaHCO3; ST changes often resolve with benzo + nitrates if vasospastic
  • cxrrequired
    imaging • used at INITIAL_WORKUP
    Aortic dissection screen (mandatory in cocaine chest pain — AHA 2008); pulmonary edema; PTX from valsalva or "crack lung"
  • tte_bedside
    imaging • used at BRANCHING_WORKUP
    Rule out stress (Takotsubo) cardiomyopathy — sympathetic surge can produce apical ballooning mimicking NSTEMI; also cocaine cardiomyopathy in chronic users
  • pattern_chronic_vs_recent_cocaine_userequired
    history • used at CONTEXT
    Chronic users (Hsue 2002 PMID 12473532) have accelerated atherosclerosis substrate → standard ACS antithrombotic load; first-time use → vasospasm-dominant
  • co_ingestantsrequired
    history • used at CONTEXT
    Alcohol → cocaethylene (more cardiotoxic); benzo / opioid co-use changes sedation strategy

12-phase flow (12)

  1. 1FRAME
    Confirm cocaine-related NSTEMI per AHA 2008 PMID 18391116 + 4th UDMI 2018 PMID 30153967 — distinguish vasospastic / thrombotic / accelerated-atherosclerosis substrates; rule out aortic dissection FIRST (AHA 2008 mandatory)
    inputs: ecg_serial, hs_troponin_serial
    advance: Cocaine etiology + dissection excluded
  2. 2ENTRY
    Triage with workup.cocaine_chest_pain pathway; concurrent serial ECG + 0/1-h hsTn; benzo first to break sympathetic crisis
    inputs: age
    actions: cocaine_chest_pain
    advance: Cocaine pathway initiated + benzodiazepine given
  3. 3CONTEXT
    Recent vs chronic use, co-ingestants (alcohol → cocaethylene), prior ACS, OAC use, allergies, mental health / substance use disorder context
    inputs: sbp, hr, creatinine_egfr, pattern_chronic_vs_recent_cocaine_use, co_ingestants
    advance: Context complete
  4. 4RED_FLAGS
    Aortic dissection (mandatory rule-out in cocaine chest pain — AHA 2008); QRS widening → NaHCO3; hyperthermia + agitation → aggressive cooling + benzo (NOT haloperidol); cardiogenic shock; sustained VT/VF
    inputs: sbp, temp
    actions: chest_pain, cocaine_chest_pain, cardiogenic_shock
    advance: Dissection ruled out + sympathetic crisis controlled
  5. 5INITIAL_WORKUP
    Serial ECG q15 min × 1 h, 0/1-h hsTn, BMP, CBC, UDS, CPK / myoglobin (rhabdo), lactate, CXR (dissection screen), echo if hemodynamic concern
    inputs: ecg_serial, hs_troponin_serial, cbc, urine_drug_screen, cpk_myoglobin, cxr
    actions: acs_pathway, panel.cardiac, panel.renal
    advance: Workup complete + dissection excluded
  6. 6BRANCHING_WORKUP
    Bedside echo for stress (Takotsubo) cardiomyopathy mimic + cocaine cardiomyopathy; CT-A only if dissection suspicion remains; cath strategy per risk (delayed 25–72 h typical unless dynamic ECG / refractory pain)
    inputs: tte_bedside
    actions: acute_valvular_emergency
    advance: Cardiomyopathy mimic excluded + cath window selected
  7. 7DIFFERENTIAL
    Cocaine-vasospastic NSTEMI vs cocaine-thrombotic NSTEMI vs accelerated-atherosclerosis NSTEMI vs Takotsubo vs aortic dissection vs myocarditis vs PE per 4th UDMI 2018 + AHA 2008
    advance: Substrate identified
  8. 8RISK_STRATIFICATION
    HEART / TIMI / GRACE band-mapped; HEART AUC 0.83 (Poldervaart PMID 23474112); cocaine substrate may underweight troponin component if vasospasm-dominant — interpret cautiously
    inputs: age, sbp, hr, creatinine_egfr, hs_troponin_serial
    actions: calc.heart, calc.timi_nstemi, calc.grace
    advance: Risk band documented
  9. 9TREATMENT
    Benzodiazepine FIRST (lorazepam 1–2 mg IV) for sympathetic crisis (AHA 2008 Class I); nitroglycerin SL/IV for coronary vasospasm + HTN; phentolamine 1–5 mg IV for refractory HTN (selective α-block); ASA + P2Y12 + UFH per standard NSTE-ACS; high-intensity statin (PROVE-IT PMID 15007110); CCB (verapamil/diltiazem) acceptable; AVOID β-blocker monotherapy acutely (ACC/AHA 2025 Class III; Lange NEJM 1989 PMID 2522592)
    inputs: creatinine_egfr, cbc
    actions: cocaine_chest_pain
    advance: Sympathetic crisis broken + ACS bundle given + BB deferred
  10. 10DISPOSITION
    Telemetry / observation 9–12 h if low-risk + troponin negative; CICU if dynamic ECG / hemodynamic instability / refractory pain; admit for substance use disorder assessment
    advance: Disposition + level-of-care set
  11. 11MONITORING
    Continuous ECG and SpO2; repeat hsTn per 0/1-h pathway; BP q15 min until <160; CPK q6 h × 24 h if rhabdo trend; bleeding signs per BARC 2011
    inputs: creatinine_egfr, cbc
    actions: panel.cardiac, panel.renal
    advance: Monitoring orders documented
  12. 12FOLLOWUP
    Cocaine cessation counseling + warm handoff to substance use disorder treatment (mortality reduction with cessation; Hollander NEJM 2008); cardiology follow-up; cardiac rehab if confirmed atherosclerotic substrate; defer BB initiation until cocaine-free ≥1 wk per AHA 2008 (Class I), then initiate per standard ACS GDMT
    advance: Substance use disorder referral + cardiology follow-up booked