Cocaine-induced myocardial ischemia and infarction: pathophysiology, recognition, and management

As cocaine abuse has become widespread, it has been associated with various cardiovascular complications, including angina pectoris, myocardial infarction, and sudden cardiac death. Cocaine's principal effects on the cardiovascular system are mediated via alpha-adrenergic stimulation and include (1) an increase in the determinants of myocardial oxygen demand (heart rate and systemic arterial pressure), and (2) a concomitant decrease in myocardial oxygen supply (caused by vasoconstriction of the epicardial coronary arteries). beta-adrenergic blocking agents may exacerbate cocaine-induced coronary arterial vasoconstriction, thereby increasing the magnitude of myocardial ischemia. In contrast, nitroglycerin and verapamil reverse cocaine-induced hypertension and coronary arterial vasoconstriction; therefore, they are the agents of choice in treating patients with cocaine-associated chest pain.