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Cocaine abuse harms CV system
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Cocaine abuse causes significant harm to the CV system through various pathways, according to a summary published in the Journal of the American College of Cardiology.
“Unfortunately, despite the Harrison Narcotics Act of 1914 (banning the nonprescription use of cocaine), this misconception [about cocaine] was present even in the 1970s, allowing a culmination of cocaine abuse with staggering numbers of more than 2 million users in the United States alone by 2007,” Ofer Havakuk, MD, of the Tel Aviv Sourasky Medical Center, and colleagues wrote. “The myriad deleterious effects of cocaine on the [CV] system were soon recognized, whereas pathophysiological mechanisms by which cocaine exerts its harmful effects continue to be explored.”
Havakuk and colleagues combined the current knowledge on cocaine and CV system and made recommendations on best treatment.
CV effects of cocaine
Cocaine can be used through several routes (IV, inhaled, mucosally absorbed), which can in turn vary the onset timing, duration and CV effects of the drug. Additionally, the hemodynamic effect is dose dependent.
Because of the inotropic and chronotropic effects of cocaine and subsequent increased peripheral vasoconstriction, individuals with cocaine abuse disorder could be at higher risk for chronic hypertension. However, a study of 3,848 young adults showed no differences between cocaine abusers and the rest of the cohort. There are not much data to explain this controversy, according to the researchers.
In two U.S. studies of aortic dissection, cocaine abuse was found to be prevalent in the populations (37% and 9.8%). Route of cocaine use may play a role, as one study found that 13 of 14 participants with cocaine-related acute aortic dissection smoked crack cocaine.
Additionally, the pathophysiology of cocaine abuse can have a deleterious effect on the oxygen supply-demand balance, which can result in individuals presenting with chest pain in the ED, according to researchers. The risk for MI has been associated with a 24-fold increase in the first hour after cocaine use. However, cocaine-related MI can be challenging to diagnose because cocaine-related chest pain is not always cardiac and abnormal ECGs are common.
Studies have shown that cocaine use can also cause acute onset of HF, with acute elevation in left ventricular pressures, LV dilation and reduction in contractility.
Cocaine, acting as a myocardial ion-channel blocker of sodium, potassium and calcium currents, can cause users to have a higher risk for arrhythmias.
Some studies have shown cocaine use is associated with an increased risk for pulmonary hypertension, stroke and vasculitis, but the evidence is inconclusive.
Treatment pathways
For MI, the American College of Cardiology/American Heart Association guidelines recommend a 12-hour observation period for those presenting with chest pain who are determined to be of low risk. This strategy was found to be safe and efficacious for cocaine abusers.
For the treatment of arrhythmias, the authors recommended assessing the patient thoroughly by checking the body temperature, hemodynamic stability, pH levels and presence of ischemia, and conducting an ECG and balancing electrolytes. Sodium bicarbonate can be used to treat cocaine toxicity, and benzodiazepines can be used to treat the heightened sympathetic tone. Nonselective beta-blockers are also a treatment option, according to researchers.
Class 1A/1C drugs should be avoided because of their similar mechanism of action as cocaine.
“Cocaine abuse represents a considerable threat to the integrity of the [CV] system. In contrast to other addictive drugs (eg, heroin, methamphetamines) that exert their harmful effects through a limited mechanism, cocaine has a multitude of pathophysiological pathways by which it affects the [CV] system,” the researchers concluded. “Discouraging reports on the contemporary prevalence of cocaine abuse in teenagers, and even in children, might serve to increase awareness of the possible deleterious future effects of this perilous agent.” – by Cassie Homer
Disclosures: The researchers report no relevant financial disclosures.
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