This handout is for cocaine-induced nstemi (sympathetic crisis + vasospasm). Your care team identified this based on: recent cocaine or sympathomimetic use (within 1–24 h) presenting with ischemic chest pain (aha 2008 pmid 18391116).
Other reasons your team may use this plan: hstn rise/fall + positive urine drug screen for cocaine / amphetamine metabolites — confirm cocaine-related nstemi; hypertension + tachycardia + agitation + diaphoresis + chest pain after cocaine use — sympathomimetic α-adrenergic crisis pattern; dynamic st depression or transient st elevation in patient with documented cocaine use — vasospasm vs thrombosis.
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 in cocaine chest pain |
| nitroglycerin | 0.4 mg SL q5 min × 3 → IV 5–200 µg/min if persistent | SL/IV | continuous IV titrate to BP and pain | AHA 2008 Class I — reverses cocaine-induced coronary vasoconstriction; 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 |
| verapamil | 5–10 mg IV slowly OR 80–120 mg PO TID | IV/PO | PRN persistent ischemia | AHA 2008 — CCB acceptable for persistent vasospasm; avoid in cardiogenic shock or severe LV dysfunction |
| aspirin | 162–325 mg load → 81 mg | PO chewed | load once → 81 mg daily | Universal NSTE-ACS — ACC/AHA 2025 Class I |
| ticagrelor | 180 mg load → 90 mg BID | PO | BID × 12 mo | PLATO PMID 19717846; ACC/AHA 2025 Class I; preferred over clopidogrel in NSTE-ACS |
| unfractionated_heparin | 60 U/kg bolus (max 4000) → 12 U/kg/h infusion | IV | continuous, aPTT 1.5–2× control | ACC/AHA 2025 Class I parenteral AC; reversible; renal-friendly |
| atorvastatin | 80 mg | PO | daily | PROVE-IT PMID 15007110 — start day 0 high-intensity per ACC/AHA 2025 Class I; especially important in chronic users with accelerated atherosclerosis (Hsue 2002) |
| carvedilol | 3.125 mg BID | PO | BID | AHA 2008 + ACC/AHA 2025 — mixed α/β agent acceptable AFTER cocaine washout (≥1 wk cocaine-free) for post-MI HF; pure β-blocker monotherapy still avoided indefinitely if active cocaine use |
Plan: Cocaine-related NSTEMI — benzo first + nitrates + phentolamine for sympathetic crisis; standard ACS antithrombotic; AVOID β-blocker monotherapy acute (AHA 2008 + ACC/AHA 2025 Class III)
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 + 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 the four foundational heart-failure medications
Guideline: 2025 ACC/AHA ACS Guideline (Rao); AHA 2008 Cocaine Cardiovascular Complications (McCord Circulation 2008 PMID 18391116); ESC 2023 NSTE-ACS Guideline (Byrne PMID 37622670)