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cardio.stemi.cocaine-induced.v1

Cocaine-induced STEMI (sympathetic crisis + vasospasm + thrombosis)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.stemi.core.v1 — sister to cardio.nstemi.cocaine-induced.v1. Pivots from universal STEMI bundle by giving benzodiazepine FIRST (lorazepam 1–2 mg IV) for sympathetic crisis per AHA 2008 PMID 18391116 Class I; then nitroglycerin + phentolamine for HTN/vasospasm; CCB acceptable (intracoronary verapamil at cath if no fixed culprit); β-blocker monotherapy AVOIDED acutely (ACC/AHA 2025 Class III) — Lange NEJM 1989 PMID 2522592 propranolol-cocaine paradox. Reperfusion: emergent PCI for persistent ST elevation despite benzo + NTG (definitive therapy). FIBRINOLYSIS controversial — case series report increased ICH risk in cocaine users; reserve for non-PCI-capable centers when transfer >120 min and ICH risk acceptable per strict BP control protocol. Mandatory aortic dissection rule-out FIRST per AHA 2008 (cocaine doubles dissection risk; AHA 2008 + ACC/AHA 2021 Chest Pain). 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 16 etiology variant.

Entry points (4)

  • history
    Recent cocaine / sympathomimetic use (within 1–24 h) presenting with ST-elevation on 12-lead ECG (AHA 2008 PMID 18391116)
    recent_cocaine_use_with_st_elevation
  • imaging
    ST elevation ≥1 mm in ≥2 contiguous leads + positive urine drug screen for cocaine / amphetamine metabolites
    st_elevation_with_positive_uds_cocaine
  • symptom
    Hypertension + tachycardia + agitation + diaphoresis + chest pain after cocaine use with new ST elevation — sympathomimetic α-adrenergic crisis pattern with full-thickness ischemia
    sympathetic_crisis_with_anginal_chest_pain_and_ecg_change
  • history
    Chronic cocaine user (>1 yr) with classic STEMI pattern — accelerated atherosclerosis substrate (Hsue Circulation 2002 PMID 12473532)
    chronic_cocaine_user_with_stemi_pattern

Required inputs (15)

  • agerequired
    demographic • used at CONTEXT
    Cocaine STEMI commoner age 30–55; younger than typical type-1 STEMI; informs differential weighting + bleeding-risk balance
  • sbprequired
    vital • used at RED_FLAGS
    Sympathetic crisis SBP often >180; gates phentolamine + nitroglycerin therapy; hypotension + STEMI = SCAI B-C cardiogenic-shock screen; 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 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
    Peak troponin proportional to infarct size; cocaine STEMI peaks similarly to type-1 STEMI; gates enzymatic rise / fall confirmation per 4th UDMI 2018 PMID 30153967
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    Rhabdomyolysis common with cocaine + agitation → AKI; influences contrast / AC dosing; cocaine + rhabdo predisposes to AKI per KDIGO 2026
  • 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; persistent ST elevation despite benzo + NTG = thrombotic substrate → emergent cath
  • cxrrequired
    imaging • used at INITIAL_WORKUP
    Aortic dissection screen (mandatory in cocaine chest pain — 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
  • echo_post_pcirequired
    imaging • used at MONITORING
    LVEF + RWMA + LV thrombus screen at 5–7 d; cocaine cardiomyopathy in chronic users may preexist
  • cor_angiorequired
    imaging • used at TREATMENT
    Culprit lesion confirmation + cocaine vasospastic vs thrombotic substrate; persistent vasospasm without fixed lesion → IC nitroglycerin / verapamil
  • 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 STEMI per AHA 2008 PMID 18391116 + 4th UDMI 2018 PMID 30153967 — distinguish vasospastic vs thrombotic vs accelerated-atherosclerosis substrates; rule out aortic dissection FIRST (AHA 2008 mandatory before heparin)
    inputs: ecg_serial, troponin
    advance: Cocaine etiology + dissection excluded
  2. 2ENTRY
    Cath lab activated within 90 min if persistent ST elevation; concurrent benzo + nitrates trial may resolve vasospastic STEMI; bedside echo for shock / mechanical complication / Takotsubo mimic
    inputs: age
    actions: cocaine_chest_pain
    advance: Cath activated or vasospasm trial selected
  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 before heparin per AHA 2008); cardiogenic shock SCAI C+ (DanGer Shock PMID 38587234 Impella benefit); 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 (peaks proportional to infarct); BMP, CBC, UDS, CPK / myoglobin (rhabdo), lactate, CXR (mandatory dissection screen), bedside echo if hemodynamic concern
    inputs: ecg_serial, troponin, urine_drug_screen, cpk_myoglobin, cxr, creatinine_egfr
    actions: acs_pathway, panel.cardiac, panel.renal
    advance: Workup complete + dissection excluded
  6. 6BRANCHING_WORKUP
    Cath lab — culprit-lesion identification; vasospasm-only (no fixed lesion) → intracoronary NTG / verapamil; thrombotic culprit → primary PCI per standard STEMI protocol
    inputs: cor_angio
    advance: Reperfusion delivered or vasospasm reversed
  7. 7DIFFERENTIAL
    Cocaine-vasospastic STEMI vs cocaine-thrombotic STEMI vs accelerated-atherosclerosis STEMI vs Takotsubo-mimic vs aortic dissection vs myocarditis per 4th UDMI 2018 + AHA 2008
    advance: Substrate identified
  8. 8RISK_STRATIFICATION
    TIMI / HEART / GRACE band-mapped (pre-cath); SCAI shock staging post-cath; cocaine substrate may underweight troponin component if vasospasm-dominant — interpret cautiously
    inputs: age, sbp, hr, creatinine_egfr, troponin
    actions: calc.timi_nstemi, calc.heart, calc.ckd_epi_2021
    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; ASA + P2Y12 + UFH per standard STEMI; high-intensity statin (PROVE-IT PMID 15007110); EMERGENT PCI if persistent ST elevation; FIBRINOLYSIS controversial — increased ICH risk in cocaine users; CCB acceptable; AVOID β-blocker monotherapy acutely (ACC/AHA 2025 Class III; Lange NEJM 1989 PMID 2522592)
    inputs: creatinine_egfr
    actions: cocaine_chest_pain, protocol.stemi
    advance: Sympathetic crisis broken + reperfusion delivered + BB deferred
  10. 10DISPOSITION
    CICU post-PCI mandatory; longer monitoring than typical STEMI given concurrent toxidrome + dissection-screen continuum; admit for substance use disorder assessment
    advance: Disposition + level-of-care set
  11. 11MONITORING
    Continuous ECG + SpO2; repeat troponin to peak; BP q15 min until <160; CPK q6 h × 24 h if rhabdo; bleeding signs per BARC 2011; echo at 5–7 d for thrombus screen + cocaine cardiomyopathy assessment
    inputs: echo_post_pci, creatinine_egfr
    actions: panel.cardiac, panel.renal
    advance: Monitoring orders documented
  12. 12FOLLOWUP
    Cocaine cessation counseling + warm handoff to substance use disorder treatment (mortality lever per Hollander NEJM 2008); cardiology follow-up; cardiac rehab; defer β-blocker initiation until cocaine-free ≥1 wk per AHA 2008 Class I, then carvedilol per standard post-MI GDMT if EF <40
    advance: Substance use disorder referral + cardiology follow-up booked