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cardio.post-arrest.cocaine-related.v1PRODUCTION
cardio.post-arrest.cocaine-related.v1

Post-cardiac-arrest care — cocaine-related arrest (sympathomimetic + Na-channel blockade)

cardiologyacuteadult
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Cocaine-related arrest = multi-mechanism (sympathomimetic VF / Na-channel-blockade wide-complex arrhythmia / coronary vasospasm / accelerated atherothrombosis); also screen for cocaine-induced dissection, ICH, mesenteric ischemia. Two pharmacologic anchors: BENZODIAZEPINE early (even during ACLS) + SODIUM BICARBONATE 1-2 mEq/kg IV for QRS >100 ms. AVOID β-blocker monotherapy. Route to parent post-arrest core for TTM + neuroprog.

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cocaine etiology + multi-mechanism differential framed

Patient inputs (24)

Age informs reversibility, ICD-eligibility framing, and SUD treatment plan; mean cocaine-arrest age younger than ischemic-arrest cohorts

Route (insufflation / smoking / IV) + timing + dose informs duration of effect, peak risk window (insufflation peak 30 min, smoking 5-15 min, IV 1-2 min), and concurrent toxicity exposure

Co-ingestion is the rule, not exception: opioids (need naloxone), alcohol (cocaethylene → prolonged toxicity), methamphetamine (synergistic sympathetic crisis), serotonergic agents (serotonin syndrome confounder)

Witnessed + initial rhythm (VF/pVT > PEA > asystole) drives prognosis; sympathomimetic VF most common; PEA more common with concurrent hyperthermia / hypovolemia / acidosis

Bystander CPR within 1 min markedly improves outcome; CAHP/OHCA score input

AED within 3-5 min critical for shockable rhythms; cocaine-related arrest often shockable initially

Cocaine intoxication arrest may overlap with suicide attempt (intentional overdose, co-ingestion) — drives mental health pathway + family meeting framing

Baseline + serial; AKI from rhabdomyolysis + post-arrest hypoperfusion + cocaine-induced renal vasospasm; KDIGO 2012 staging

12-lead ECG immediately post-ROSC + serial; QRS >100 ms triggers sodium bicarbonate; QTc prolongation common with cocaine + co-ingestion; Brugada-like pattern from Na-channel blockade resolves with bicarb; ST changes screen for cocaine-ACS confounder

Echo for LVEF (cocaine cardiomyopathy + post-arrest stunning), wall-motion abnormalities (cocaine ACS), valvular vegetations (IVDU endocarditis screen), aortic root for dissection screen

CXR for rib fractures from CPR, pulmonary edema (cocaine-related ARDS / negative-pressure pulmonary edema after seizure), aspiration pneumonia, mediastinal widening (dissection screen)

Urine drug screen for cocaine metabolites (benzoylecgonine), opioids, methamphetamine, MDMA, PCP, cannabinoids, benzodiazepines (baseline before iatrogenic admin); benzoylecgonine detectable up to 3-5 d post-use

Cocaine ACS occurs in 6% of cocaine chest-pain ED visits; serial troponin q3-6h × 24h to characterize ischemic substrate vs post-arrest stunning vs catecholamine cardiomyopathy

Cocaine + agitated delirium + hyperthermia + seizure → severe rhabdomyolysis; CK > 5000 demands aggressive volume + alkalinization; informs renal replacement decision

Tissue hypoperfusion + post-arrest perfusion debt + sympathetic-mediated hyperlactatemia; trajectory drives prognosis (SCAI 2022 PMID 35718438)

Cocaine + sympathetic surge + bicarb therapy + rhabdomyolysis cause profound electrolyte derangement; K + Mg + Ca + Phos correction essential to stabilize myocardium

ABG for acid-base status (lactic acidosis common); guides sodium bicarbonate dosing for QRS widening + acidosis correction

Post-ROSC HTN crisis common from residual sympathetic surge; SBP guides α-blocker / nitrate / CCB selection (β-blocker monotherapy AVOIDED); SCAI staging if shock

Hyperthermia (>38.5 °C) common with cocaine + agitation + seizures + serotonergic co-ingestion; aggressive active cooling first, then standard TTM 32-36 °C × 24h per TTM2 PMID 34133859

Avoid hyperoxia post-ROSC; SpO2 92-98% (AHA 2020 Class IIa)

Cocaine intoxication carries 7x risk of intracerebral hemorrhage from acute HTN crisis + cocaine vasculopathy; CT head if focal neuro deficit, persistent coma post-rewarm, or seizures

CT angio if cocaine + chest pain + asymmetric pulses → dissection; CT abdomen if abdominal pain + lactate / acidosis disproportionate → mesenteric ischemia from cocaine-induced vasospasm

Cocaine arrest in pregnancy → cross-link to peripartum-arrest engine; placental abruption risk

IV cocaine use → IVDU pattern; baseline HIV + HCV screening; informs endocarditis pretest probability

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

Severity triggers (5)

5 need judgement
  • informationallife_threateningpersistent_qrs_widening_despite_bicarb_in_cocaine_arrest
    QRS persistently >100 ms despite 2-3 boluses of sodium bicarbonate (1-2 mEq/kg each) — refractory Na-channel blockade; consider lipid emulsion salvage + ECPR if shock
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrecurrent_vf_after_inadvertent_beta_blocker_exposure_in_cocaine_intoxication
    β-blocker administered (e.g., labetalol or metoprolol) in patient with active cocaine intoxication → unopposed α-stimulation → recurrent VF / refractory HTN crisis / coronary vasospasm worsening
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrepeat_cocaine_arrest_within_hours_to_days
    Patient with prior cocaine arrest re-presents with second arrest within hours to days — continued cocaine use without engagement of addiction medicine; high mortality
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcocaine_induced_dissection_or_ich_complicating_arrest
    Cocaine arrest complicated by aortic dissection (chest pain + asymmetric pulses + mediastinal widening on CXR) OR intracerebral hemorrhage (focal neuro deficit + persistent coma + acute HTN history)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresuicide_attempt_with_co_ingestion_in_cocaine_arrest
    Cocaine arrest in context of intentional overdose / suicide attempt with co-ingestion (opioids, alcohol, antipsychotics, antidepressants) — mental health emergency overlay; safety planning + 1:1 sitter + family + addiction medicine
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Cocaine-related arrest resuscitation phenotype — benzo + bicarb + AVOID β-blocker monotherapy + standard post-ROSC bundle (AHA 2008 PMID 18391116 + AHA 2020 ACLS PMID 33081530 + ACC/AHA 2025 ACS Class III β-blocker monotherapy in active cocaine intoxication)
axis: cocaine_arrest_resuscitation_phenotype
Selected axis "Cocaine-related arrest resuscitation phenotype — benzo + bicarb + AVOID β-blocker monotherapy + standard post-ROSC bundle (AHA 2008 PMID 18391116 + AHA 2020 ACLS PMID 33081530 + ACC/AHA 2025 ACS Class III β-blocker monotherapy in active cocaine intoxication)" by default fallback (first axis)
  • lorazepam
    first line
    benzodiazepine_short_acting
    1-2 mg IV q5-15 min titrate sympathetic blunting + agitation + seizure • IV • titrated to effect
    triggers: cocaine_intoxication_arrest, cocaine_associated_chest_pain, cocaine_induced_agitated_delirium, cocaine_seizure, sympathetic_surge_post_rosc
    AHA 2008 cocaine PMID 18391116 — benzodiazepine first-line for cocaine-related cardiovascular toxicity; central sympathetic blunting reduces vasospasm + ischemia + HTN + agitation; consider during ACLS for adjunct sympathetic component
    rxcui 6470
  • sodium bicarbonate
    first line
    alkalinizing_agent_na_channel_unblocker
    1-2 mEq/kg IV bolus then 150 mEq in 1 L D5W infusion to maintain pH 7.45-7.55 • IV • bolus + infusion
    triggers: qrs_widening_above_100ms_post_cocaine_arrest, recurrent_wide_complex_vt_vf, na_channel_blockade_pattern_brugada_like
    AHA 2010 toxicology PMID 20956224 + Lange NEJM 1989 PMID 2522592 — Na load + alkalinization overcomes cocaine Na-channel blockade; analogous to TCA-overdose bicarb pathway
    rxcui 36676
  • epinephrine
    first line
    inotrope_chronotrope_vasopressor
    1 mg IV q3-5 min during arrest • IV • standard ACLS
    triggers: cardiac_arrest_during_index_event
    AHA 2020 ACLS standard; cocaine arrest does not contraindicate ACLS epinephrine despite sympathomimetic concern (mortality benefit dominates)
    rxcui 3992
  • amiodarone
    first line
    class_iii_antiarrhythmic
    300 mg IV bolus → 150 mg if recurrent → 1 mg/min × 6h → 0.5 mg/min × 18h • IV • standard ACLS dosing
    triggers: refractory_vf_pvt_post_cocaine_arrest, sustained_vt_with_pulse
    AHA 2020 ACLS Class IIb; preferred over lidocaine in cocaine arrest given Na-channel blockade contribution (lidocaine theoretically additive but evidence sparse — may use as second-line)
    rxcui 703
  • norepinephrine
    first line
    vasopressor_alpha1_beta1
    0.05-0.5 µg/kg/min titrate MAP ≥65 • IV • continuous
    triggers: post_rosc_vasoplegia_after_cocaine_wears_off, cocaine_cardiomyopathy_with_shock
    SOAP-II PMID 20200382; first-line vasopressor; cocaine effect wears off → vasoplegia possible despite initial hypertensive crisis
    rxcui 7512
  • nitroglycerin
    first line
    nitrate_vasodilator
    0.4 mg SL or 5-200 µg/min IV titrate • IV/SL • continuous
    triggers: cocaine_associated_chest_pain_with_vasospasm, post_rosc_hypertensive_crisis
    AHA 2008 PMID 18391116 — nitrate first-line for cocaine vasospastic ischemia + HTN; benzo + nitrate combination preferred over β-blocker
    rxcui 4917
  • diltiazem
    first line
    non_dihydropyridine_ccb
    10-20 mg IV bolus then 5-15 mg/h titrate • IV • titrated
    triggers: cocaine_associated_chest_pain_with_vasospasm_unresponsive_to_benzo_nitrate, cocaine_atrial_arrhythmia_with_rvr
    AHA 2008 PMID 18391116 — non-DHP CCB for cocaine vasospasm or rate control; alternative to verapamil
    rxcui 3443
  • phentolamine
    second line
    alpha_adrenergic_antagonist
    5-15 mg IV q5-15 min • IV • titrated
    triggers: cocaine_severe_hypertensive_crisis_unresponsive_to_benzo_nitrate
    AHA 2008 PMID 18391116 — pure α-blockade for refractory cocaine HTN; reverses unopposed α-stimulation; preferred over β-blocker monotherapy
    rxcui 8153
  • magnesium sulfate
    add on
    electrolyte_anti_arrhythmic
    2 g IV over 15 min then 1-2 g/h titrate Mg 2-2.5 • IV • continuous if TdP
    triggers: torsades_de_pointes_post_cocaine_arrest, qtc_prolongation_post_arrest, low_serum_mg
    AHA 2020 ACLS Class IIa for TdP; cocaine + co-ingestion (methadone, antipsychotics) prolong QTc; Mg replacement essential
    rxcui 6585
  • naloxone
    first line
    opioid_antagonist
    0.4-2 mg IV / IM / IN q2-3 min • IV • titrated to respiratory recovery
    triggers: concurrent_opioid_co_ingestion_with_respiratory_depression, fentanyl_contamination_in_cocaine_supply
    AHA 2020; fentanyl-contaminated cocaine increasingly common; naloxone first-line if any opioid co-ingestion suspicion + respiratory depression
    rxcui 7242
  • propofol
    first line
    sedative_iv_anesthetic
    5-50 µg/kg/min • IV • continuous; titrate RASS
    triggers: post_rosc_intubation_ttm, cocaine_agitation_post_intubation
    PADIS 2018; propofol additive sympatholytic effect helpful in cocaine-related sympathetic surge
    rxcui 8782
  • fentanyl
    first line
    opioid_analgesic
    25-200 µg/h • IV • continuous
    triggers: post_rosc_intubation_ttm, shivering_control
    PADIS 2018; analgesia + shivering suppression for TTM
    rxcui 4337
  • metoprolol
    rescue
    beta_blocker_beta1_selective
    AVOID monotherapy in active cocaine intoxication — only after 24-48h cocaine washout AND with concurrent α-blockade or after cocaine fully metabolized • PO • do_not_use_acutely
    triggers: contraindicated_in_active_cocaine_intoxication_per_aha_2008_acc_aha_2025
    Lange NEJM 1989 PMID 2522592 + AHA 2008 PMID 18391116 + ACC/AHA 2025 ACS Class III — β-blocker monotherapy in active cocaine intoxication produces unopposed α-stimulation, worsening coronary vasospasm + HTN; only consider after 24-48h washout for chronic GDMT if cocaine cardiomyopathy + HFrEF + sustained abstinence
    rxcui 6918

outpatient playbook — drug actions (2)

  1. 1. continue secondary-prevention GDMT if HFrEF persists past 12 mo
    rxcui 1656328
    ARNI + BB + MRA + SGLT2i at max tolerated • PO • as scheduled
    trigger: persistent HFrEF
    TRED-HF PMID 30429051; AHA 2022
  2. 2. continue naloxone rescue kit
    rxcui 7242
    naloxone 4 mg IN • IN • rescue
    trigger: ongoing opioid co-ingestion risk
    Harm-reduction

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: ROSC after cardiac arrest with documented or suspected cocaine intoxication — sympathetic crisis + Na-channel blockade arrest pattern; Witnessed collapse in known cocaine user (recent insufflation, smoking, or IV use) — high pre-test probability sympathomimetic VF / pVT or cocaine ACS arrest; Cocaine user with agitated delirium + hyperthermia + seizure progressing to arrest — sympathetic crisis pattern; immediate benzodiazepine + cooling + bicarb-ready.

Objective

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

Assessment

**Post-cardiac-arrest care — cocaine-related arrest (sympathomimetic + Na-channel blockade)** (cardio.post-arrest.cocaine-related.v1).
Phenotype framing: Pure cocaine arrest (sympathomimetic VF + Na-blockade) vs cocaine ACS arrest vs cocaine-induced dissection arrest vs cocaine ICH arrest vs unmasked underlying disease (Brugada, LQTS) vs concurrent opioid overdose (need naloxone) vs polysubstance / suicide attempt — drives long-term plan
Scope: Cocaine-related arrest = multi-mechanism (sympathomimetic VF / Na-channel-blockade wide-complex arrhythmia / coronary vasospasm / accelerated atherothrombosis); also screen for cocaine-induced dissection, ICH, mesenteric ischemia. Two pharmacologic anchors: BENZODIAZEPINE early (even during ACLS) + SODIUM BICARBONATE 1-2 mEq/kg IV for QRS >100 ms. AVOID β-blocker monotherapy. Route to parent post-arrest core for TTM + neuroprog.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Cocaine-related arrest resuscitation phenotype — benzo + bicarb + AVOID β-blocker monotherapy + standard post-ROSC bundle (AHA 2008 PMID 18391116 + AHA 2020 ACLS PMID 33081530 + ACC/AHA 2025 ACS Class III β-blocker monotherapy in active cocaine intoxication)**.
1. lorazepam 1-2 mg IV q5-15 min titrate sympathetic blunting + agitation + seizure IV titrated to effect (benzodiazepine_short_acting, first line) — AHA 2008 cocaine PMID 18391116 — benzodiazepine first-line for cocaine-related cardiovascular toxicity; central sympathetic blunting reduces vasospasm + ischemia + HTN + agitation; consider during ACLS for adjunct sympathetic component
2. sodium bicarbonate 1-2 mEq/kg IV bolus then 150 mEq in 1 L D5W infusion to maintain pH 7.45-7.55 IV bolus + infusion (alkalinizing_agent_na_channel_unblocker, first line) — AHA 2010 toxicology PMID 20956224 + Lange NEJM 1989 PMID 2522592 — Na load + alkalinization overcomes cocaine Na-channel blockade; analogous to TCA-overdose bicarb pathway
3. epinephrine 1 mg IV q3-5 min during arrest IV standard ACLS (inotrope_chronotrope_vasopressor, first line) — AHA 2020 ACLS standard; cocaine arrest does not contraindicate ACLS epinephrine despite sympathomimetic concern (mortality benefit dominates)
4. amiodarone 300 mg IV bolus → 150 mg if recurrent → 1 mg/min × 6h → 0.5 mg/min × 18h IV standard ACLS dosing (class_iii_antiarrhythmic, first line) — AHA 2020 ACLS Class IIb; preferred over lidocaine in cocaine arrest given Na-channel blockade contribution (lidocaine theoretically additive but evidence sparse — may use as second-line)
5. norepinephrine 0.05-0.5 µg/kg/min titrate MAP ≥65 IV continuous (vasopressor_alpha1_beta1, first line) — SOAP-II PMID 20200382; first-line vasopressor; cocaine effect wears off → vasoplegia possible despite initial hypertensive crisis
6. nitroglycerin 0.4 mg SL or 5-200 µg/min IV titrate IV/SL continuous (nitrate_vasodilator, first line) — AHA 2008 PMID 18391116 — nitrate first-line for cocaine vasospastic ischemia + HTN; benzo + nitrate combination preferred over β-blocker
7. diltiazem 10-20 mg IV bolus then 5-15 mg/h titrate IV titrated (non_dihydropyridine_ccb, first line) — AHA 2008 PMID 18391116 — non-DHP CCB for cocaine vasospasm or rate control; alternative to verapamil
8. phentolamine 5-15 mg IV q5-15 min IV titrated (alpha_adrenergic_antagonist, second line) — AHA 2008 PMID 18391116 — pure α-blockade for refractory cocaine HTN; reverses unopposed α-stimulation; preferred over β-blocker monotherapy
9. magnesium sulfate 2 g IV over 15 min then 1-2 g/h titrate Mg 2-2.5 IV continuous if TdP (electrolyte_anti_arrhythmic, add on) — AHA 2020 ACLS Class IIa for TdP; cocaine + co-ingestion (methadone, antipsychotics) prolong QTc; Mg replacement essential
10. naloxone 0.4-2 mg IV / IM / IN q2-3 min IV titrated to respiratory recovery (opioid_antagonist, first line) — AHA 2020; fentanyl-contaminated cocaine increasingly common; naloxone first-line if any opioid co-ingestion suspicion + respiratory depression
11. propofol 5-50 µg/kg/min IV continuous; titrate RASS (sedative_iv_anesthetic, first line) — PADIS 2018; propofol additive sympatholytic effect helpful in cocaine-related sympathetic surge
12. fentanyl 25-200 µg/h IV continuous (opioid_analgesic, first line) — PADIS 2018; analgesia + shivering suppression for TTM
13. metoprolol AVOID monotherapy in active cocaine intoxication — only after 24-48h cocaine washout AND with concurrent α-blockade or after cocaine fully metabolized PO do_not_use_acutely (beta_blocker_beta1_selective, rescue) — Lange NEJM 1989 PMID 2522592 + AHA 2008 PMID 18391116 + ACC/AHA 2025 ACS Class III — β-blocker monotherapy in active cocaine intoxication produces unopposed α-stimulation, worsening coronary vasospasm + HTN; only consider after 24-48h washout for chronic GDMT if cocaine cardiomyopathy + HFrEF + sustained abstinence

Setting playbook (outpatient) — Long-term cardiology + addiction medicine + mental health surveillance; sustained abstinence support (contingency management, mental health, peer support); harm reduction if continued use; ICD evaluation only if unmasked Brugada or persistent LVEF <35 on full GDMT after 90 d sustained abstinence
14. continue secondary-prevention GDMT if HFrEF persists past 12 mo ARNI + BB + MRA + SGLT2i at max tolerated PO as scheduled — persistent HFrEF (TRED-HF PMID 30429051; AHA 2022)
15. continue naloxone rescue kit naloxone 4 mg IN IN rescue — ongoing opioid co-ingestion risk (Harm-reduction)

Non-pharmacologic actions:
- Contingency-management program long-term
- Mental health long-term
- Peer support / 12-step / SMART recovery as patient-preferred
- Family CPR + AED maintenance
- Naloxone rescue kit refill
- NO ICD if structurally normal heart + sustained abstinence (revisit only if unmasked Brugada or persistent LVEF <35 on full GDMT at 90 d)

AVOID / contraindication checks:
- Beta_blocker_monotherapy_AVOID_in_active_cocaine_intoxication_class_iii (Lange NEJM 1989 PMID 2522592 + AHA 2008 PMID 18391116 + ACC/AHA 2025 ACS)
- Start_benzodiazepine_early_for_cocaine_chest_pain_or_arrest_first_line (AHA 2008 PMID 18391116)
- Sodium_bicarbonate_1_to_2_meq_kg_iv_bolus_for_qrs_above_100ms_post_cocaine_arrest (AHA 2010 toxicology PMID 20956224)
- Aggressive_cooling_for_hyperthermia_above_38_5c_before_standard_TTM_targets (AHA 2020 + cocaine hyperthermia mortality)
- Naloxone_for_concurrent_opioid_co_ingestion_with_respiratory_depression (fentanyl cocaine contamination increasingly common)
- Phentolamine_for_refractory_cocaine_HTN_not_labetalol_acutely (pure α blockade preferred over mixed α/β in active intoxication)
- Icd_only_if_unmasked_brugada_or_persistent_lvef_below_35_post_recovery (channelopathy or true cardiomyopathy after sustained abstinence)
- Contingency_management_first_line_behavioral_intervention_for_stimulant_use_disorder (Petry meta analyses)

Monitoring

Regimen monitoring:
- continuous ecg telemetry x 48h with qrs and qtc (cocaine + metabolites prolonged arrhythmogenic effect; bicarb-induced QRS narrowing may rebound)
- serial ecg q4-6h x 24h (capture Brugada-like pattern emergence + resolution)
- serial troponin q3-6h x 24h (4th UDMI 2018; characterize cocaine ACS subcomponent)
- CK total q6-12h until below 1000 (rhabdomyolysis trend)
- BMP q6h with K Mg Ca Phos (cocaine + bicarb cause profound electrolyte derangement)
- continuous core temp via bladder or esophageal probe (TTM2)
- continuous EEG for 24-48h (Sandroni 2021; cocaine seizure substrate)
- NSE at 24h 48h 72h (Sandroni 2021)
- lactate q2-4h until normalized (SCAI 2022)
- urine output target 1-2 mL kg hr for rhabdomyolysis diuresis
- echo at 24-48h for LVEF and wall motion (cocaine cardiomyopathy + post-arrest stunning + ACS sequelae)

Setting (outpatient) monitoring:
- Quarterly cardiology + addiction medicine + mental health
- Annual echo if cardiomyopathy + ECG + cancer / lipid / HbA1c per primary care
- UDS per addiction medicine engagement

Follow-up plan: Cardiology follow-up at 2-4 weeks: echo for LVEF (cocaine cardiomyopathy reversibility with sustained abstinence); EP follow-up if Brugada-like ECG persisted post-bicarb (genuine Brugada channelopathy unmasked vs cocaine-induced); ADDICTION MEDICINE primary follow-up: contingency-management program enrollment (highest-evidence behavioral intervention for stimulant-use disorder per Petry meta-analyses), naloxone rescue kit for opioid co-ingestion risk, mental health PTSD/depression workup, hep C / HIV testing if IVDU pattern; family CPR + AED training; if pregnancy → OB / NICU pathway
- Close-out criterion: cardiology + EP + addiction medicine + mental health + family CPR pathway booked

Monitoring phase: Continuous telemetry × 48h (cocaine + metabolites have prolonged arrhythmogenic effect; bicarb-induced QRS narrowing may rebound); serial ECG q4-6h × 24h with QRS + QTc; serial troponin q3-6h × 24h; multimodal neuroprog ≥72h post-rewarm (Sandroni 2021 PMID 33745427); BMP + extended electrolytes q6h; CK trend until <1000; lactate q2-4h until normalized; UDS confirmatory at 24-48h

Disposition

Current setting: outpatient — Long-term cardiology + addiction medicine + mental health surveillance; sustained abstinence support (contingency management, mental health, peer support); harm reduction if continued use; ICD evaluation only if unmasked Brugada or persistent LVEF <35 on full GDMT after 90 d sustained abstinence

Disposition criteria:
- Long-term continuation; cross-link to cardio.cardiomyopathy.cocaine.v1 (if cocaine cardiomyopathy persistent), cardio.brugada.v1 (if true Brugada substrate identified), or appropriate addiction-medicine engine for stimulant-use disorder long-term

Escalation triggers (move to higher acuity):
- Recurrent cocaine arrest → ED + cardiology + addiction medicine emergent
- Recurrent cocaine use with cardiac symptoms → cardiology urgent
- Suicide attempt → ED emergent
- Opioid overdose with naloxone administration → ED + addiction medicine urgent
- Unmasked Brugada or persistent LVEF <35 → EP for ICD evaluation

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] QRS persistently >100 ms despite 2-3 boluses of sodium bicarbonate (1-2 mEq/kg each) — refractory Na-channel blockade; consider lipid emulsion salvage + ECPR if shock
- [LIFE_THREATENING] β-blocker administered (e.g., labetalol or metoprolol) in patient with active cocaine intoxication → unopposed α-stimulation → recurrent VF / refractory HTN crisis / coronary vasospasm worsening
- [LIFE_THREATENING] Patient with prior cocaine arrest re-presents with second arrest within hours to days — continued cocaine use without engagement of addiction medicine; high mortality

Citations

- AHA 2008 Cocaine-Associated Chest Pain Scientific Statement + AHA 2020 ACLS / Post-Cardiac-Arrest Care + ACC/AHA 2025 ACS Guideline + Lange NEJM 1989 cocaine + propranolol + AHA 2010 toxicology bicarb + TTM2 + Sandroni 2021 [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 20956224) [PMID:20956224](https://pubmed.ncbi.nlm.nih.gov/20956224/)
- Cited evidence (PMID 33081530) [PMID:33081530](https://pubmed.ncbi.nlm.nih.gov/33081530/)
- Cited evidence (PMID 34133859) [PMID:34133859](https://pubmed.ncbi.nlm.nih.gov/34133859/)

Last reconciled with current guidelines: 2026-05-15.
References
  • AHA 2008 Cocaine-Associated Chest Pain Scientific Statement + AHA 2020 ACLS / Post-Cardiac-Arrest Care + ACC/AHA 2025 ACS Guideline + Lange NEJM 1989 cocaine + propranolol + AHA 2010 toxicology bicarb + TTM2 + Sandroni 2021 — PMID:18391116
  • Cited evidence (PMID 2522592) — PMID:2522592
  • Cited evidence (PMID 20956224) — PMID:20956224
  • Cited evidence (PMID 33081530) — PMID:33081530
  • Cited evidence (PMID 34133859) — PMID:34133859