A prehospital acute coronary syndrome in a cocaine user: an unstable clinical situation
Nicolas Franchitto1, Claudine Cabot, Nicolas Dumonteil
1Pôle de Médecine d'Urgence, Centre Hospitalier Universitaire Purpan, Place du Dr-Baylac, Toulouse Cedex 9, France. franchitto.n@chu-toulouse.fr
Insights
Cocaine users presenting with chest pain require careful emergency evaluation. Myocardial bridging, not acute coronary syndrome, was diagnosed in a cocaine user with chest pain and ECG changes.
Area of Science:
- Cardiology
- Emergency Medicine
- Toxicology
Background:
- Chest pain is a frequent emergency department complaint in cocaine users.
- Diagnosing acute coronary syndromes (ACS) in this population is challenging due to cocaine's cardiovascular effects.
- Prehospital management by a physician is a key feature in French emergency medical services.
Observation:
- A 30-year-old cocaine user presented with constrictive chest pain and a normal initial ECG.
- Subepicardial ischemia was noted on a subsequent ECG during transport.
- Coronary angiography revealed myocardial bridging in the anterior interventricular artery, with no significant coronary lesions.
Findings:
- Cocaine-induced coronary artery spasm was initially suspected.
- The final diagnosis was myocardial bridging, a condition where a segment of a coronary artery travels through heart muscle.
- ECG abnormalities in cocaine users can mimic ACS but may be due to other causes.
Implications:
- Emergency physicians must consider myocardial bridging in cocaine users with chest pain and ECG changes.
- Timely diagnosis and appropriate management are crucial in these high-risk patients.
- Understanding the nuances of ECG interpretation in cocaine-intoxicated individuals is vital for effective prehospital care.
Abstract:
Chest pain is a common reason why cocaine-addicted patients call the emergency department, and acute coronary syndromes are difficult to diagnose in these situations. A 30-year-old cocaine-user patient contacts the Emergency Medical Assistance Service with constrictive chest pain. A doctor is sent out to the patient at home. The initial ECG is normal. No other aetiology of chest pain is revealed, except nicotine and cocaine addictions. First, a coronary artery spasm is suggested, caused by the injection of cocaine. During the journey, the patient indicates that the chest pain has returned. A 12-lead ECG shows repolarisation abnormality in the form of a subepicardial ischaemia. Fibrinolysis is not prescribed in view of the patient's history and of the proximity of the interventional cardiology team. The coronary angiogram enables the diagnosis of myocardial bridging in the middle anterior interventricular artery, and no significant lesion of the coronary arteries is noted. A particular feature of prehospital management in France is that medical care can be given in the early stages by a physician who is called by the patient. This case report discusses the specific care requirements of which the emergency physician needs to be aware in the context of this unstable clinical situation due to the urgency associated with the difficulties of ECG diagnosis of ST-segment elevation in cocaine users.
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