Cocaine and the Heart

John L. Tan, MD, PhD

Presbyterian Hospital of Dallas
 Clinical Case
 IB is a 44 y/o painter who recently
presented with a prolonged episode of
chest discomfort
 His history was pertinent for smoking
cocaine within the past 72 hours
 Physical examination was unremarkable
 Clinical Case

 ECG revealed only non-specific

ST/T- wave abnormalities
 Initial cardiac enzymes were
within normal limits
Epidemiology of Cocaine Use

 ~25 million Americans admit to using

cocaine at least once (1999)
 ~1.5 million are active users

1999 National Household Survey on Drug Abuse

Epidemiology of Cocaine Use

 Cocaine is the most commonly used

illicit drug among patients seen in
the ER and drug-treatment centers
 Cocaine is the most frequent cause of
drug-related deaths
1999 National Household Survey on Drug Abuse
 Erythoxylon
coca
 Native to eastern slopes of
Andes
 Cocaine alkaloid serves as
natural pesticide
 Leaves contain 0.1-0.9%
cocaine

www.cocaine.org
Cocaine Inc.

www.cocaine.org
Cocaine Inc.

www.cocaine.org
Cocaine Hydrochloride

www.cocaine.org
Free-base cocaine: Crack

www.cocaine.org
Pharmacokinetics of Cocaine

NEJM, 345:351, 2001

 Metabolism of Cocaine

 Serum half life of 45-90 minutes

 Only 1% of the drug is recovered in urine
after ingestion
 Cocaine can be detected in blood or urine
only for several hours after its use
 Metabolism of Cocaine

 Cocaine metabolites are detectable for

2-5 days
 Hair analysis provides a very sensitive
marker for cocaine use within the
preceding weeks to months
 Cocaine: A Short History

 In pre-Columbian times, the coca leaf was

officially reserved for Inca royalty
 Later used by natives but initially banned
by the Spanish
 Labeled “an evil agent of the Devil”
 Cocaine: A Short History

 Without it, natives could barely work the

fields or gold mines, . . .So,
Distributed to workers 3-4 times a day
Cultivated even by the Catholic Church
 Cocaine: A Short History
 Active ingredient isolated by Albert
Niemann in 1860
 Widely used recreationally and
medicinally in late 1800’s
 The first cocaine cartel, the Cocaine
Manufacturers’ Syndicate, founded
in 1910
 The First Cocaine Cartel

www.cocaine.org
Merck, along with Sandoz, and Hoffman-LaRoche
A Panacea for Your Ills

www.cocaine.org
A Panacea for Your Ills

www.cocaine.org
 A Panacea for Your Ills
“ sustains and refreshes both the body and
brain. . .It may be taken at any time with perfect
safety. . . It has been effectually proven that in
the same space of time more than double the
amount of work could be undergone when
Peruvian Wine of Coca was used, and positively
no fatigue experienced. . .”

Sears, Roebuck and Co. Consumers’ Guide (1900)

 A Panacea for Your Ills: Coca
Wine Lovers
• Anatole France • Queen Victoria
• Henrik Ibsen • King George I (Greece)
• Jules Verne • King Alphonse XIII
• Alexander Dumas • Shah of Persia
• Robert L. Stephenson • William McKinley
• Sir Arthur C. Doyle
• Grand Rabbi of France
• Massenet
• Pope Pius X
• Gounod
• • Pope Leo XIII
Faure
The Pope on Coke

www.cocaine.org
 American Ingenuity
 John Pemberton (1832-1888)
Pemberton’s French wine coca
“an intellectual beverage”
“a most wonderful invigorator of the
sexual organs”
 American Ingenuity
 Introduction of Prohibition in 1886
Pemberton’s French wine coca

Coca-Cola
The temperance drink
 American Ingenuity
 Coca-Cola
 “Offering the virtues of coca
without the vices of alcohol”
 “a valuable brain-tonic and cure
for all nervous afflictions”
 The Real Thing: 60 mg cocaine per
serving (until 1903)
 Mechanism of Action

Cocaine blocks the presynaptic reuptake of NE and dopamine, producing an

excess of these neurotransmitters at the postsynaptic receptor site, thereby
acting as a powerful sympathomimetic agent
NEJM, 345:351, 2001
Cocaine-induced Baroreflex
Activation

Circulation 105:1054, 2002

Cardiovascular Consequences of
Cocaine Use
 Myocardial  Dilated
ischemia/infarction cardiomyopathies
 Hypertensive Crisis  Stroke
 Aortic Dissection  Limb Ischemia
 Cardiac arrhythmias  Endocarditis
(VT/VF)  Acceleration of
 Myocarditis atherosclerosis
 Mechanisms of
Cocaine-related Ischemia

NEJM, 345:351, 2001

 Medical Epidemiology of
Cocaine
 Estimated 175,000 cocaine-related ER
visits annually
 Approximately 40% (>70,000) are due to
chest pain
 Of these, ~57% are admitted to the hospital,
at an annual cost of $ 83 million in
hospitalization expenses alone
Risk of Myocardial Ischemia and
Infarction in Cocaine Users

 Cocaine use increases risk of acute MI by

24-fold during the first hour after its use
 Cocaine users have a 7-fold increase in
their lifetime risk of MI than non-users
Risk of Myocardial Ischemia and
Infarction in Cocaine Users
 Cocaine use accounts for up to 25% of
AMI in patients 18-45 years of age
 The risk of MI is unrelated to amount of
drug used, route of administration, or the
frequency of use
Possibly a Once in a Life-time
Experience

www.cocaine.org
 Challenges in Diagnosing
Cocaine-related Acute MI
 ECGs are abnormal in 56-84% of cocaine
users with chest pain

 Up to 43% of cocaine users with chest

pain, but no MI, may present with
>0.1mV ST-segment elevation
 Challenges in Diagnosing
Cocaine-related Acute MI
 Serum CK enzymes are elevated in 50%
of cocaine users who do not have MI,
presumably from rhabdomyolysis

 Serum troponins may be more specific in

diagnosing MI in this population

 About half the patients with cocaine-

related MI’s have normal coronary
arteries on cardiac cath
Complications of Cocaine-related
Acute MI
 Most complications occur within 12 hours
after presentation to the ER

 Incidence of arrhythmias and heart failure

is relatively low, compared to general
pool of patients with MIs
Observational Unit Care for
Cocaine-induced Chest Pain

NEJM 348:510, 2003

Clinical Recommendations

NEJM, 345:351, 2001