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cardio.nstemi.cocaine-induced.v1PRODUCTION
cardio.nstemi.cocaine-induced.v1

Cocaine-induced NSTEMI (sympathetic crisis + vasospasm)

cardiologyacuteadult
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12/12 authored

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

Current phase

Frame

Detailed

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)

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Advance rule
Set
Advance when

Cocaine etiology + dissection excluded

Patient inputs (14)

Cocaine NSTEMI commoner age 30–55; younger than typical type-1 NSTE-ACS; informs differential weighting

Sinus tachycardia >120 typical; QRS widening warns of Na-channel blockade requiring NaHCO3 (workup.cocaine_chest_pain)

Chronic users (Hsue 2002 PMID 12473532) have accelerated atherosclerosis substrate → standard ACS antithrombotic load; first-time use → vasospasm-dominant

Alcohol → cocaethylene (more cardiotoxic); benzo / opioid co-use changes sedation strategy

Confirms cocaine / amphetamine exposure; benzoylecgonine detectable 2–4 d post-use; informs disposition and substance-use treatment referral

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

Rhabdomyolysis common with cocaine + agitation → AKI; influences contrast / AC dosing

Baseline before AC; rule out concomitant infection (endocarditis from IV cocaine use)

Rhabdomyolysis screen — common with cocaine + agitation + restraint; gates aggressive IVF

Dynamic ECG q15 min × 1 h; QRS widening (Na-channel blockade) → NaHCO3; ST changes often resolve with benzo + nitrates if vasospastic

Aortic dissection screen (mandatory in cocaine chest pain — AHA 2008); pulmonary edema; PTX from valsalva or "crack lung"

Sympathetic crisis SBP often >180; gates phentolamine + nitroglycerin therapy; rule out aortic dissection if discordant arm BPs

Hyperthermia >39 + agitation = severe cocaine toxicity → aggressive cooling + benzodiazepine (NOT antipsychotic)

Rule out stress (Takotsubo) cardiomyopathy — sympathetic surge can produce apical ballooning mimicking NSTEMI; also cocaine cardiomyopathy in chronic users

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

Severity triggers (5)

5 need judgement
  • informationallife_threateningcocaine_related_arrhythmia
    Sustained VT/VF or wide-complex tachycardia in cocaine NSTEMI — Na-channel blockade contribution; AVOID procainamide (additive Na-block); amiodarone first-line; NaHCO3 if QRS ≥100 ms
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepersistent_chest_pain_on_max_benzo
    Persistent chest pain after maximum benzodiazepine + nitroglycerin + phentolamine — implies fixed coronary lesion or ongoing severe vasospasm needing emergent cath
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebeta_blocker_exposure_error_in_acute_cocaine_use
    Inadvertent β-blocker administration to a patient with active cocaine use — risk of unopposed-α coronary vasoconstriction and worsened ischemia
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererhabdomyolysis_with_aki_in_cocaine_nstemi
    CPK >5000 + myoglobinuria + creatinine rise in cocaine NSTEMI — common with agitation + restraint + hyperthermia; aggressive IVF + monitor for compartment syndrome and dialysis
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterecurrent_cocaine_use_during_or_after_admission
    Recurrent cocaine use during admission or shortly after discharge — escalates substance use disorder treatment intensity and re-evaluates DAPT / dissection risk
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

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)
axis: cocaine_nstemi_phenotype
Selected axis "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)" by default fallback (first axis)
  • lorazepam
    first line
    benzodiazepine
    1–2 mg IV • IV • q5–15 min PRN sympathetic crisis
    triggers: cocaine_use_with_chest_pain, sympathetic_crisis, agitation
    AHA 2008 Class I (PMID 18391116) — benzo breaks sympathetic crisis, reduces myocardial oxygen demand and BP in cocaine chest pain
    rxcui 6470
  • nitroglycerin
    first line
    nitrate_vasodilator
    0.4 mg SL q5 min × 3 → IV 5–200 µg/min if persistent • SL/IV • continuous IV titrate to BP and pain
    triggers: cocaine_chest_pain_with_HTN, coronary_vasospasm_suspected
    AHA 2008 Class I — reverses cocaine-induced coronary vasoconstriction; preferred over BB acutely
    rxcui 4917
  • phentolamine
    second line
    alpha_blocker_nonselective
    1–5 mg IV q5–15 min • IV • PRN refractory HTN
    triggers: refractory_HTN_after_benzo_and_NTG, severe_alpha_adrenergic_crisis
    AHA 2008 Class IIa — selective α-block reverses cocaine-induced vasoconstriction without unopposed-α paradox
    rxcui 8153
  • verapamil
    add on
    non_dihydropyridine_ccb
    5–10 mg IV slowly OR 80–120 mg PO TID • IV/PO • PRN persistent ischemia
    triggers: persistent_chest_pain_after_benzo_NTG, recurrent_vasospasm
    AHA 2008 — CCB acceptable for persistent vasospasm; avoid in cardiogenic shock or severe LV dysfunction
    rxcui 11170
  • aspirin
    first line
    antiplatelet_cox1
    162–325 mg load → 81 mg • PO chewed • load once → 81 mg daily
    triggers: cocaine_nstemi_confirmed
    Universal NSTE-ACS — ACC/AHA 2025 Class I
    rxcui 1191
  • ticagrelor
    first line
    P2Y12_inhibitor
    180 mg load → 90 mg BID • PO • BID × 12 mo
    triggers: cocaine_nstemi_pci_planned
    PLATO PMID 19717846; ACC/AHA 2025 Class I; preferred over clopidogrel in NSTE-ACS
    rxcui 1116632
  • unfractionated_heparin
    first line
    parenteral_anticoagulant
    60 U/kg bolus (max 4000) → 12 U/kg/h infusion • IV • continuous, aPTT 1.5–2× control
    triggers: cocaine_nstemi_pci_planned
    ACC/AHA 2025 Class I parenteral AC; reversible; renal-friendly
    rxcui 5224
  • atorvastatin
    first line
    statin_high_intensity
    80 mg • PO • daily
    triggers: cocaine_nstemi_confirmed
    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)
    rxcui 83367
  • carvedilol
    comorbidity specific
    mixed_alpha_beta_blocker
    3.125 mg BID • PO • BID
    triggers: post_MI_EF_lt_40_AND_cocaine_free_ge_1_week, documented_chronic_HF
    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
    rxcui 20352

outpatient playbook — drug actions (3)

  1. 1. continue DAPT through 12 mo
    aspirin 81 + ticagrelor 90 BID • PO • daily/BID
    trigger: Post-cath maintenance
    PARIS adherence-vs-stent-thrombosis; PLATO PMID 19717846
  2. 2. first up-titration of ACEi
    lisinopril 5 → 10 → 20 → 40 mg • PO • daily
    trigger: SBP >100 + K <5.0 + eGFR stable
    GISSI-3 mortality benefit at target dose
  3. 3. consider mixed α/β carvedilol if EF<40 + cocaine-free ≥1 mo
    carvedilol 3.125 → 6.25 → 12.5 → 25 BID • PO • BID
    trigger: Sustained cocaine cessation + post-MI HFrEF
    AHA 2008 + ACC/AHA 2025 — case-by-case after extended washout

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Recent cocaine or sympathomimetic use (within 1–24 h) presenting with ischemic chest pain (AHA 2008 PMID 18391116); 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.

Objective

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

Assessment

**Cocaine-induced NSTEMI (sympathetic crisis + vasospasm)** (cardio.nstemi.cocaine-induced.v1).
Phenotype framing: 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
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **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)**.
1. lorazepam 1–2 mg IV IV q5–15 min PRN sympathetic crisis (benzodiazepine, first line) — AHA 2008 Class I (PMID 18391116) — benzo breaks sympathetic crisis, reduces myocardial oxygen demand and BP in cocaine chest pain
2. nitroglycerin 0.4 mg SL q5 min × 3 → IV 5–200 µg/min if persistent SL/IV continuous IV titrate to BP and pain (nitrate_vasodilator, first line) — AHA 2008 Class I — reverses cocaine-induced coronary vasoconstriction; preferred over BB acutely
3. phentolamine 1–5 mg IV q5–15 min IV PRN refractory HTN (alpha_blocker_nonselective, second line) — AHA 2008 Class IIa — selective α-block reverses cocaine-induced vasoconstriction without unopposed-α paradox
4. verapamil 5–10 mg IV slowly OR 80–120 mg PO TID IV/PO PRN persistent ischemia (non_dihydropyridine_ccb, add on) — AHA 2008 — CCB acceptable for persistent vasospasm; avoid in cardiogenic shock or severe LV dysfunction
5. aspirin 162–325 mg load → 81 mg PO chewed load once → 81 mg daily (antiplatelet_cox1, first line) — Universal NSTE-ACS — ACC/AHA 2025 Class I
6. ticagrelor 180 mg load → 90 mg BID PO BID × 12 mo (P2Y12_inhibitor, first line) — PLATO PMID 19717846; ACC/AHA 2025 Class I; preferred over clopidogrel in NSTE-ACS
7. unfractionated_heparin 60 U/kg bolus (max 4000) → 12 U/kg/h infusion IV continuous, aPTT 1.5–2× control (parenteral_anticoagulant, first line) — ACC/AHA 2025 Class I parenteral AC; reversible; renal-friendly
8. atorvastatin 80 mg PO daily (statin_high_intensity, first line) — 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)
9. carvedilol 3.125 mg BID PO BID (mixed_alpha_beta_blocker, comorbidity specific) — 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

Setting playbook (outpatient) — Long-term secondary prevention — sustained cocaine cessation is the dominant mortality lever; chronic ACS bundle; reassess BB candidacy as cocaine-free interval extends
10. continue DAPT through 12 mo aspirin 81 + ticagrelor 90 BID PO daily/BID — Post-cath maintenance (PARIS adherence-vs-stent-thrombosis; PLATO PMID 19717846)
11. first up-titration of ACEi lisinopril 5 → 10 → 20 → 40 mg PO daily — SBP >100 + K <5.0 + eGFR stable (GISSI-3 mortality benefit at target dose)
12. consider mixed α/β carvedilol if EF<40 + cocaine-free ≥1 mo carvedilol 3.125 → 6.25 → 12.5 → 25 BID PO BID — Sustained cocaine cessation + post-MI HFrEF (AHA 2008 + ACC/AHA 2025 — case-by-case after extended washout)

Non-pharmacologic actions:
- Reinforce daily BP + symptom log
- Cardiac rehab attendance reinforcement
- Substance use disorder treatment retention reinforcement
- Mediterranean / DASH diet counseling

AVOID / contraindication checks:
- Beta_blocker_monotherapy_AVOID_in_acute_cocaine_use (ACC/AHA 2025 Class III; Lange NEJM 1989 PMID 2522592)
- Antithrombotic_block_if_active_bleeding (ACC/AHA 2025)
- Phentolamine_AVOID_severe_CAD_without_concurrent_NTG (AHA 2008)
- Verapamil_AVOID_in_severe_LV_dysfunction_or_AV_block (AHA 2008)
- Haloperidol_AVOID_in_cocaine_agitation_use_benzo_instead (AHA 2008)
- Succinylcholine_avoid_if_rhabdo_with_hyperkalemia (anesthesia consult)

Monitoring

Regimen monitoring:
- Continuous ECG + SpO2 + BP q15 min until SBP <160 (AHA 2008)
- Repeat hsTn per ESC 2023 0/1-h pathway
- CPK / myoglobin q6 h × 24 h if rhabdo trend
- Hgb q12 h on triple antithrombotic (BARC 2011)
- Creatinine q24 h on AC + post-contrast (KDIGO 2026)

Setting (outpatient) monitoring:
- BMP at week 4
- Lipid panel at week 4–8 — target LDL <70 (or <55 very-high-risk); add ezetimibe if above per IMPROVE-IT
- Bleeding signs at every visit through 12 mo of DAPT

Follow-up plan: 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
- Close-out criterion: Substance use disorder referral + cardiology follow-up booked

Monitoring phase: 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

Disposition

Current setting: outpatient — Long-term secondary prevention — sustained cocaine cessation is the dominant mortality lever; chronic ACS bundle; reassess BB candidacy as cocaine-free interval extends

Disposition criteria:
- Formal handoff to chronic CAD engine when cocaine-free ≥3 mo + GDMT optimized + DAPT plan finalised

Escalation triggers (move to higher acuity):
- Recurrent chest pain → ED
- BARC 2+ bleed → reassess DAPT — TWILIGHT PMID 31475798 or MASTER DAPT PMID 34516952 if HAS-BLED ≥3
- Cocaine relapse → urgent re-evaluation + substance use disorder intensification

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Sustained VT/VF or wide-complex tachycardia in cocaine NSTEMI — Na-channel blockade contribution; AVOID procainamide (additive Na-block); amiodarone first-line; NaHCO3 if QRS ≥100 ms
- [SEVERE] Persistent chest pain after maximum benzodiazepine + nitroglycerin + phentolamine — implies fixed coronary lesion or ongoing severe vasospasm needing emergent cath
- [SEVERE] Inadvertent β-blocker administration to a patient with active cocaine use — risk of unopposed-α coronary vasoconstriction and worsened ischemia

Citations

- 2025 ACC/AHA ACS Guideline (Rao); AHA 2008 Cocaine Cardiovascular Complications (McCord Circulation 2008 PMID 18391116); ESC 2023 NSTE-ACS Guideline (Byrne PMID 37622670) [PMID:18391116](https://pubmed.ncbi.nlm.nih.gov/18391116/)
- Cited evidence (PMID 2522592) [PMID:2522592](https://pubmed.ncbi.nlm.nih.gov/2522592/)
- Cited evidence (PMID 12473532) [PMID:12473532](https://pubmed.ncbi.nlm.nih.gov/12473532/)
- Cited evidence (PMID 37622670) [PMID:37622670](https://pubmed.ncbi.nlm.nih.gov/37622670/)
- Cited evidence (PMID 34669377) [PMID:34669377](https://pubmed.ncbi.nlm.nih.gov/34669377/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 2025 ACC/AHA ACS Guideline (Rao); AHA 2008 Cocaine Cardiovascular Complications (McCord Circulation 2008 PMID 18391116); ESC 2023 NSTE-ACS Guideline (Byrne PMID 37622670) — PMID:18391116
  • Cited evidence (PMID 2522592) — PMID:2522592
  • Cited evidence (PMID 12473532) — PMID:12473532
  • Cited evidence (PMID 37622670) — PMID:37622670
  • Cited evidence (PMID 34669377) — PMID:34669377