Content area
Full text
Cocaine abuse can cause a variety of cardiovascular emergencies, especially myocardial ischemia and infarction and is one of the leading causes of emergency room visits for chest pain evaluation in the young population. 1 In 1998, 1.7 million Americans were using cocaine at least once per month, with the highest rates of use among Americans age 18 to 25 years. 2 We present a unique case of cocaine abuse with multiple life-threatening cardiovascular effects.
A 43-year-old African American man presented to emergency room with shortness of breath of 4 hours' duration. He had chest pain earlier in the day, described as a mild pressure-like sensation localized in the substernal area, which gradually got better. Past medical history was significant for untreated hypertension. Family history was noncontributory. The patient admitted to tobacco, ethanol, and cocaine abuse for years, including cocaine within the last 12 hours.
On examination he was alert, oriented, and in minimal distress because of dyspnea. Vital signs were pulse, 130 beats/min; blood pressure, 120/70 mm Hg and equal in both arms and legs; afebrile; and respiratory rate, 20/min. No jugular venous distension noticed. Carotid upstroke was normal without audible bruits. Chest examination revealed basal crackles bilaterally. Examination of the heart revealed a nondisplaced point of maximal impulse. First and second heart sounds were normal; a third heart sound was heard at the apex with a grade 2/6 holosystolic murmur of mitral regurgitation. No aortic regurgitation murmur was audible. Abdominal, rectal, and neurological examination was unremarkable.
Initial laboratory data revealed that complete blood count, blood urea nitrogen, creatinine, and electrolytes were normal; total creatinine kinase, 133 mg/dL; creatinine kinase-MB fraction, 4.1; Relative Index, 4.1; and Troponin (I), 2.1. Urine drug screen was positive for cocaine metabolites. Chest X-ray showed mild cardiomegaly and prominent upper lobe vasculature, but no mediastinal widening ( Figure 1 ). A 12-lead electrocardiogram revealed atrial flutter, with a ventricular rate of 130 beats/min and nonspecific T wave changes.
Initial diagnoses were mild congestive heart failure, cocaine-induced myocardial infarction with mitral regurgitation secondary to papillary muscle dysfunction, and cocaine induced...