The STEMI Mimic: Cocaine-Associated Pulmonary Embolism With ST-Segment Elevation

Cocaine has been linked to both myocardial infarction (MI) and pulmonary embolism (PE), with the latter occasionally mimicking acute coronary syndrome. We report a 54-year-old man with polysubstance abuse who was found unresponsive and revived with naloxone. He developed chest pain with electrocardiogram showing ST-segment elevation in V2-V3 and elevated troponin, suggestive of anteroseptal ST-elevation MI (STEMI). Bedside echocardiography revealed right ventricular dilation and dysfunction without left ventricular abnormalities, prompting computed tomography angiography (CTA), which demonstrated large bilateral pulmonary emboli with right heart strain. He was anticoagulated and later discharged on a direct oral anticoagulant; coronary angiography revealed only mild nonobstructive disease. This case underscores the diagnostic challenge of distinguishing PE from STEMI in patients with cocaine use and highlights the utility of point-of-care echocardiography in avoiding unnecessary invasive procedures. Clinicians should consider PE in the differential diagnosis of chest pain with ST elevation.