This handout is for cocaine-induced stemi (sympathetic crisis + vasospasm + thrombosis). Your care team identified this based on: recent cocaine / sympathomimetic use (within 1–24 h) presenting with st-elevation on 12-lead ecg (aha 2008 pmid 18391116).
Other reasons your team may use this plan: st elevation ≥1 mm in ≥2 contiguous leads + positive urine drug screen for cocaine / amphetamine metabolites; hypertension + tachycardia + agitation + diaphoresis + chest pain after cocaine use with new st elevation — sympathomimetic α-adrenergic crisis pattern with full-thickness ischemia; chronic cocaine user (>1 yr) with classic stemi pattern — accelerated atherosclerosis substrate (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; first-line in cocaine STEMI |
| 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; may resolve vasospastic STEMI before cath |
| 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 |
| verapamil | 5–10 mg IV slowly OR 80–120 mg PO TID; intracoronary 100–200 µg if vasospasm at cath | IV/IC/PO | PRN persistent ischemia or refractory vasospasm | AHA 2008 — CCB acceptable for persistent vasospasm; intracoronary verapamil at cath if no fixed culprit; avoid in cardiogenic shock or severe LV dysfunction |
| aspirin | 162–325 mg load → 81 mg | PO chewed | load once → 81 mg daily | Universal STEMI — ACC/AHA 2025 Class I; same as parent cardio.stemi.core.v1 |
| ticagrelor | 180 mg load → 90 mg BID | PO | BID × 12 mo | PLATO PMID 19717846; ACC/AHA 2025 Class I; preferred over clopidogrel in STEMI |
| unfractionated heparin | 70–100 U/kg bolus → infusion to ACT 250–300 during PCI | IV | continuous, ACT-guided | ACC/AHA 2025 Class I parenteral AC; reversible; renal-friendly; AVOID until aortic dissection ruled out per AHA 2008 |
| 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 PMID 12473532) |
| carvedilol | 3.125 mg BID titrate | PO | BID | AHA 2008 + ACC/AHA 2025 — mixed α/β agent acceptable AFTER cocaine washout (≥1 wk cocaine-free); pure β-blocker monotherapy still avoided indefinitely if active cocaine use; CAPRICORN PMID 11356436 for post-MI HF |
Plan: Cocaine-related STEMI — benzo first + nitrates + phentolamine for sympathetic crisis; emergent PCI for thrombotic substrate; standard ACS antithrombotic; AVOID β-blocker monotherapy acute (AHA 2008 + ACC/AHA 2025 Class III); fibrinolysis controversial — increased ICH risk
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 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 the four foundational heart-failure medications if EF <40
Guideline: 2025 ACC/AHA ACS Guideline (Rao); AHA 2008 Cocaine Cardiovascular Complications (McCord Circulation 2008 PMID 18391116); ESC 2023 ACS Guideline (Byrne PMID 37622670)