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Cocaine-Associated ACS — RACP Adult Medicine MCQ

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ModerateEmergency MedicineCocaine-Associated ACSRACP Adult Medicine

A 58-year-old man develops acute chest pain and ST elevation after cocaine use. Troponin is elevated. What is the critical difference in management compared to standard STEMI?

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Correct answer: E — Standard STEMI management applies without modification

In cocaine-associated ACS, beta-blockers are CONTRAINDICATED as they cause unopposed alpha-receptor stimulation, worsening coronary vasospasm and hypertension. Management includes IV benzodiazepines (first-line for sympathetic excess), GTN (coronary vasodilation), aspirin, and consideration of PCI for STEMI. Phentolamine (alpha-blocker) is an alternative vasodilator. Calcium channel blockers may also be used. If beta-blockade is needed for tachycardia, labetalol (combined alpha/beta) is preferred over pure beta-blockers.

Reference: eTG – 2025 – Toxicology; AHA – 2021 – Cocaine and ACS Guidance