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Cocaine ACS Management — EECC MCQ

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ModerateCoronary Artery DiseaseCocaine ACS ManagementEECC

A 45-year-old man with cocaine use presents with acute chest pain and ST elevation in V1-V4. Troponin is elevated. He is agitated with BP 200/120 mmHg and HR 130 bpm. What is the specific management consideration?

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Correct answer: E — Benzodiazepines for sedation and coronary vasospasm relief; IV nitrates and phentolamine for hypertension; beta-blockers should be avoided acutely due to risk of unopposed alpha-mediated coronary vasoconstriction

Cocaine-associated ACS has unique pathophysiology: (1) coronary vasospasm (alpha-adrenergic stimulation); (2) accelerated atherosclerosis; (3) in situ thrombus formation (platelet activation); (4) increased myocardial oxygen demand (tachycardia, hypertension). Critical management differences: AVOID beta-blockers acutely — beta-2 blockade removes the counterbalancing vasodilatory effect, leading to unopposed alpha-mediated coronary vasoconstriction and hypertensive crisis. Instead: (1) benzodiazepines (anxiolysis reduces sympathetic drive and cocaine-mediated vasoconstriction); (2) nitrates (coronary vasodilator); (3) phentolamine (alpha-blocker) for refractory hypertension; (4) aspirin, heparin, PCI for STEMI as per standard guidelines. After the acute cocaine effects resolve (12-24 hours), beta-blockers may be cautiously introduced.

Reference: https://www.nice.org.uk/guidance/conditions-and-diseases/cardiovascular-conditions