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cardio.hypertensive-emergency.cocaine-sympathetic-crisis.v1PRODUCTION
cardio.hypertensive-emergency.cocaine-sympathetic-crisis.v1

Cocaine / sympathomimetic hypertensive crisis (alpha-driven HTN + tachycardia + coronary vasospasm)

cardiologyacuteadult
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Canonical 12-phase frame with authored status for this dossier.

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Detailed

Cocaine / sympathomimetic HTN crisis = alpha-adrenergic-driven vasoconstriction + tachycardia + coronary vasospasm + risk of MI/stroke/aortic dissection. Pharmacology pivot: BENZODIAZEPINE FIRST for sympatholysis; AVOID β-blocker monotherapy (unopposed alpha → worse HTN + vasospasm — Lange NEJM 1989 PMID 2522592; AHA 2008 PMID 18391116; ACC/AHA 2025 ACS Class III). Route to parent engine for shared HTN-emergency arc; this dossier owns the toxidrome-aware pharmacology + ACS rule-out.

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sympathomimetic etiology confirmed by history or UDS

Patient inputs (12)

Younger patients overrepresented; older users have higher coronary disease prevalence + worse outcomes (Hollander NEJM 2008)

Confirms sympathomimetic etiology — cocaine/meth/MDMA/MAOI-tyramine/pseudoephedrine — drives AVOID list (no β-blocker monotherapy)

Cocaine-associated MI in up to 6% of cocaine-chest-pain ED visits (Hollander NEJM 2008 PMID 18172180); drives troponin + ECG cascade

STEMI pattern, ischemia, QTc prolongation, demand ischemia from tachycardia all relevant

Cocaine-associated MI rate up to 6%; serial troponin q3-6h × 2 to rule out (Hollander NEJM 2008)

Confirms cocaine (3-d window for benzoylecgonine), amphetamine class, fentanyl/opioid co-ingestion

Rhabdomyolysis + AKI common in stimulant toxidrome → drives volume resuscitation + drug dosing

Rhabdomyolysis screen — common in stimulant + hyperthermia + agitation; CK >5000 → aggressive IV fluids

Defines crisis threshold; drives titration of phentolamine + nitroglycerin

Component of MAP; DBP >120 supports emergency criterion + alpha-overdrive severity

Sympathetic-driven tachycardia + risk of demand ischemia; HR >120 plus HTN drives benzo-first decision

Hyperthermia (>40 C) signals sympathomimetic toxidrome severity / serotonin syndrome overlap → aggressive cooling

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningcocaine_associated_stemi_or_acs
    Cocaine/stimulant use within 24-72 h + STEMI on ECG OR positive troponin trajectory — cocaine-associated MI (rate ~6% per Hollander NEJM 2008)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsympathomimetic_hyperthermia_above_40c
    Core temperature >40 C in cocaine/stimulant toxidrome — risk of multi-organ failure + DIC + death
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcocaine_aortic_dissection
    Cocaine + acute severe back/chest pain + BP differential between arms or pulse deficit — cocaine raises aortic dissection risk 4-5× (Hsue Circulation 2002)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcocaine_intracranial_hemorrhage
    Cocaine/stimulant + sudden severe headache OR new focal deficit OR seizure — cocaine ICH risk (cocaine + HTN + arteritis-like vasculopathy)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcocaine_wide_complex_tachycardia
    Wide-complex tachycardia / brugada-pattern in cocaine toxidrome — sodium-channel blockade by cocaine (TCA-like)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecocaine_takotsubo_cardiomyopathy
    Cocaine + new severe LV apical ballooning + chest pain + minimal CAD on cath — Takotsubo (stress cardiomyopathy) precipitated by cocaine catecholamine surge
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Cocaine / sympathomimetic HTN crisis — benzodiazepine-first sympatholysis; AVOID β-blocker monotherapy (unopposed alpha); phentolamine reverses alpha-vasoconstriction
axis: cocaine_sympathomimetic_htn_crisis_pharmacology
Selected axis "Cocaine / sympathomimetic HTN crisis — benzodiazepine-first sympatholysis; AVOID β-blocker monotherapy (unopposed alpha); phentolamine reverses alpha-vasoconstriction" by default fallback (first axis)
  • lorazepam
    first line
    benzodiazepine
    1-2 mg IV q5-10 min PRN, max 8 mg in 1 h • IV • PRN
    triggers: sympathomimetic_crisis, agitation_or_seizure_or_hyperthermia
    AHA 2008 Class I PMID 18391116 — benzodiazepine first for sympatholysis (reduces HTN + tachy + agitation); diazepam alternative; titrate to symptom control
    rxcui 6470
  • diazepam
    first line
    benzodiazepine
    5-10 mg IV q5-10 min • IV • PRN
    triggers: sympathomimetic_crisis, agitation_seizure
    AHA 2008 — alternative to lorazepam; longer half-life advantageous for sustained sympatholysis
    rxcui 3322
  • nitroglycerin
    second line
    organic_nitrate
    5-200 mcg/min IV titrate q3-5 min • IV • continuous
    triggers: persistent_HTN_after_benzo, cocaine_chest_pain_with_ischemia
    AHA 2008 Class IIa — vasodilator + coronary vasodilator; reverses cocaine coronary vasoconstriction; preferred over β-blocker
    rxcui 4917
  • phentolamine
    second line
    alpha_adrenergic_blocker
    1-5 mg IV q5-15 min titrate • IV • PRN bolus
    triggers: persistent_HTN_after_benzo_and_NTG, documented_coronary_vasospasm
    Boehrer Am J Med 1993 PMID 8390052 — pure alpha-blocker reverses cocaine alpha-vasoconstriction + reverses coronary vasospasm; AHA 2008 Class IIa
    rxcui 8153
  • verapamil
    second line
    non_DHP_CCB
    5-10 mg IV slow push q15-30 min OR 0.075-0.15 mg/kg • IV • PRN bolus
    triggers: cocaine_chest_pain_with_vasospasm, tachycardia_with_HTN
    Negus Circulation 1994 — verapamil reverses cocaine coronary vasospasm; AHA 2008 Class IIa CCB acceptable
    rxcui 11170
  • diltiazem
    second line
    non_DHP_CCB
    0.25 mg/kg IV bolus then 5-15 mg/h infusion • IV • continuous
    triggers: cocaine_HTN_with_AF_or_tachycardia
    AHA 2008 — alternative non-DHP CCB; useful if AF + RVR
    rxcui 3443
  • labetalol
    add on
    mixed_alpha_beta_blocker
    AVOID as first-line; if used: 10-20 mg IV q10 min • IV • bolus
    triggers: HTN_and_tachy_after_benzo_and_NTG_and_phento_failed
    AHA 2008 — labetalol is debated; mixed α/β theoretically OK but small case reports of paradoxical HTN; AVOID as first-line; reasonable as add-on if benzo + NTG + phentolamine inadequate
    rxcui 6185
  • AVOID metoprolol/esmolol/propranolol
    contraindication substitute
    do_not_use
    AVOID • N/A • N/A
    triggers: cocaine_or_sympathomimetic_exposure
    Lange NEJM 1989 PMID 2522592 — propranolol potentiates cocaine coronary vasoconstriction (unopposed alpha); AHA 2008 Class III; ACC/AHA 2025 ACS Class III β-blocker monotherapy in cocaine ACS
  • AVOID succinylcholine if rhabdomyolysis
    contraindication substitute
    do_not_use
    AVOID • N/A • N/A
    triggers: rhabdomyolysis_with_hyperK
    Hyperkalemia from rhabdomyolysis + succinylcholine = arrest risk; use rocuronium for RSI

outpatient playbook — drug actions (3)

  1. 1. continue HTN regimen
    rxcui 17767
    Amlodipine 5-10 ± lisinopril ± chlorthalidone • PO • daily
    trigger: Stable maintenance
    ACC/AHA 2025
  2. 2. beta-blocker for cardio-protection if MI history + abstinence
    rxcui 20352
    Carvedilol 6.25-25 mg BID titrate • PO • BID
    trigger: Post-MI + confirmed abstinence × ≥2 wk
    CAPRICORN PMID 11356436 + AHA 2008 acceptable post-clearance
  3. 3. continue MOUD if OUD
    rxcui 7242
    Per protocol • PO/SL • daily
    trigger: OUD
    Long-term MAT

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Cocaine, methamphetamine, MDMA, or sympathomimetic use within 24-72 h + SBP ≥180 / DBP ≥120 (AHA 2008 PMID 18391116; Hollander NEJM 2008 PMID 18172180); Hypertensive crisis + tachycardia + diaphoresis + agitation + dilated pupils + chest pain — sympathomimetic toxidrome; ECG ischemia/STEMI pattern in setting of acute cocaine/stimulant use — cocaine-associated ACS pathway.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cocaine / sympathomimetic hypertensive crisis (alpha-driven HTN + tachycardia + coronary vasospasm)** (cardio.hypertensive-emergency.cocaine-sympathetic-crisis.v1).
Scope: Cocaine / sympathomimetic HTN crisis = alpha-adrenergic-driven vasoconstriction + tachycardia + coronary vasospasm + risk of MI/stroke/aortic dissection. Pharmacology pivot: BENZODIAZEPINE FIRST for sympatholysis; AVOID β-blocker monotherapy (unopposed alpha → worse HTN + vasospasm — Lange NEJM 1989 PMID 2522592; AHA 2008 PMID 18391116; ACC/AHA 2025 ACS Class III). Route to parent engine for shared HTN-emergency arc; this dossier owns the toxidrome-aware pharmacology + ACS rule-out.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Cocaine / sympathomimetic HTN crisis — benzodiazepine-first sympatholysis; AVOID β-blocker monotherapy (unopposed alpha); phentolamine reverses alpha-vasoconstriction**.
1. lorazepam 1-2 mg IV q5-10 min PRN, max 8 mg in 1 h IV PRN (benzodiazepine, first line) — AHA 2008 Class I PMID 18391116 — benzodiazepine first for sympatholysis (reduces HTN + tachy + agitation); diazepam alternative; titrate to symptom control
2. diazepam 5-10 mg IV q5-10 min IV PRN (benzodiazepine, first line) — AHA 2008 — alternative to lorazepam; longer half-life advantageous for sustained sympatholysis
3. nitroglycerin 5-200 mcg/min IV titrate q3-5 min IV continuous (organic_nitrate, second line) — AHA 2008 Class IIa — vasodilator + coronary vasodilator; reverses cocaine coronary vasoconstriction; preferred over β-blocker
4. phentolamine 1-5 mg IV q5-15 min titrate IV PRN bolus (alpha_adrenergic_blocker, second line) — Boehrer Am J Med 1993 PMID 8390052 — pure alpha-blocker reverses cocaine alpha-vasoconstriction + reverses coronary vasospasm; AHA 2008 Class IIa
5. verapamil 5-10 mg IV slow push q15-30 min OR 0.075-0.15 mg/kg IV PRN bolus (non_DHP_CCB, second line) — Negus Circulation 1994 — verapamil reverses cocaine coronary vasospasm; AHA 2008 Class IIa CCB acceptable
6. diltiazem 0.25 mg/kg IV bolus then 5-15 mg/h infusion IV continuous (non_DHP_CCB, second line) — AHA 2008 — alternative non-DHP CCB; useful if AF + RVR
7. labetalol AVOID as first-line; if used: 10-20 mg IV q10 min IV bolus (mixed_alpha_beta_blocker, add on) — AHA 2008 — labetalol is debated; mixed α/β theoretically OK but small case reports of paradoxical HTN; AVOID as first-line; reasonable as add-on if benzo + NTG + phentolamine inadequate
8. AVOID metoprolol/esmolol/propranolol AVOID N/A N/A (do_not_use, contraindication substitute) — Lange NEJM 1989 PMID 2522592 — propranolol potentiates cocaine coronary vasoconstriction (unopposed alpha); AHA 2008 Class III; ACC/AHA 2025 ACS Class III β-blocker monotherapy in cocaine ACS
9. AVOID succinylcholine if rhabdomyolysis AVOID N/A N/A (do_not_use, contraindication substitute) — Hyperkalemia from rhabdomyolysis + succinylcholine = arrest risk; use rocuronium for RSI

Setting playbook (outpatient) — Long-term cardiology + addiction medicine + PCP coordination — sustained SUD remission, BP <130/80, secondary prevention if MI history, harm reduction for relapse
10. continue HTN regimen Amlodipine 5-10 ± lisinopril ± chlorthalidone PO daily — Stable maintenance (ACC/AHA 2025)
11. beta-blocker for cardio-protection if MI history + abstinence Carvedilol 6.25-25 mg BID titrate PO BID — Post-MI + confirmed abstinence × ≥2 wk (CAPRICORN PMID 11356436 + AHA 2008 acceptable post-clearance)
12. continue MOUD if OUD Per protocol PO/SL daily — OUD (Long-term MAT)

Non-pharmacologic actions:
- Sustained engagement in addiction medicine
- Naloxone refilled
- Cardiac rehab if MI history
- Annual cardiology follow-up

AVOID / contraindication checks:
- Beta_blocker_monotherapy_avoid_in_cocaine_or_sympathomimetic (AHA 2008 PMID 18391116; ACC/AHA 2025 ACS Class III)
- Propranolol_potentiates_cocaine_coronary_vasoconstriction (Lange NEJM 1989 PMID 2522592)
- Succinylcholine_avoid_with_rhabdomyolysis_hyperK
- Thrombolytics_caution_in_cocaine_HTN_due_to_ICH_risk_prefer_PCI (AHA 2008)
- Benzo_first_then_NTG_then_phentolamine_then_CCB (AHA 2008 algorithm)

Monitoring

Regimen monitoring:
- continuous ECG q15min BP (AHA 2008)
- serial troponin q3-6h x2 (Hollander NEJM 2008 PMID 18172180)
- serial ECG q4h x12-24h (AHA 2008)
- CK q6h if rhabdomyolysis suspected
- temperature q15-30min with active cooling if >40C
- mental status and agitation assessment q1h
- UOP target >1mL/kg/h if rhabdomyolysis

Setting (outpatient) monitoring:
- Quarterly BP + addiction visit
- Annual ECG + lipid + A1c
- Annual echo if prior LV dysfunction

Follow-up plan: Substance use disorder counseling + treatment (matrix model for stimulant, contingency management evidence-based per Stitzer 2010); cardiology follow-up if MI occurred (high-risk for recurrent cocaine-MI); echo if Takotsubo suspected (cocaine is precipitant); BP regimen if persistent HTN; opioid agonist therapy if fentanyl-laced supply suspected; harm reduction
- Close-out criterion: SUD treatment booked + cardiology follow-up + BP regimen if needed

Monitoring phase: Continuous ECG + telemetry; q15-30 min BP; serial troponin q3-6h × 2; CK q6h if rhabdomyolysis; UOP; mental status

Disposition

Current setting: outpatient — Long-term cardiology + addiction medicine + PCP coordination — sustained SUD remission, BP <130/80, secondary prevention if MI history, harm reduction for relapse

Disposition criteria:
- Long-term continuation; cross-link to cardio.htn.core.v1 + addiction medicine for chronic management

Escalation triggers (move to higher acuity):
- Relapse with chest pain → ED
- BP rebound → urgent visit

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Cocaine/stimulant use within 24-72 h + STEMI on ECG OR positive troponin trajectory — cocaine-associated MI (rate ~6% per Hollander NEJM 2008)
- [LIFE_THREATENING] Core temperature >40 C in cocaine/stimulant toxidrome — risk of multi-organ failure + DIC + death
- [LIFE_THREATENING] Cocaine + acute severe back/chest pain + BP differential between arms or pulse deficit — cocaine raises aortic dissection risk 4-5× (Hsue Circulation 2002)

Citations

- AHA 2008 Cocaine Cardiovascular Complications Scientific Statement (McCord PMID 18391116) + 2025 ACC/AHA ACS Guideline (Class III β-blocker monotherapy) + 2025 ACC/AHA HTN (Whelton) [PMID:18391116](https://pubmed.ncbi.nlm.nih.gov/18391116/)
- Cited evidence (PMID 18172180) [PMID:18172180](https://pubmed.ncbi.nlm.nih.gov/18172180/)
- Cited evidence (PMID 2522592) [PMID:2522592](https://pubmed.ncbi.nlm.nih.gov/2522592/)
- Cited evidence (PMID 8390052) [PMID:8390052](https://pubmed.ncbi.nlm.nih.gov/8390052/)
- Cited evidence (PMID 38613493) [PMID:38613493](https://pubmed.ncbi.nlm.nih.gov/38613493/)

Last reconciled with current guidelines: 2026-05-14.
References
  • AHA 2008 Cocaine Cardiovascular Complications Scientific Statement (McCord PMID 18391116) + 2025 ACC/AHA ACS Guideline (Class III β-blocker monotherapy) + 2025 ACC/AHA HTN (Whelton) — PMID:18391116
  • Cited evidence (PMID 18172180) — PMID:18172180
  • Cited evidence (PMID 2522592) — PMID:2522592
  • Cited evidence (PMID 8390052) — PMID:8390052
  • Cited evidence (PMID 38613493) — PMID:38613493