Correspondence

Use of Phentolamine for Cocaine-Induced Myocardial Ischemia

N Engl J Med 1992; 327:361July 30, 1992

Article

To the Editor:

Over 100 cases of cocaine-associated myocardial infarction have been reported since it was first described in 1982.1 , 2 Cocaine-induced myocardial ischemia results from coronary vasoconstriction, enhanced platelet aggregation, increased myocardial oxygen demand, and possibly accelerated atherogenesis in patients with long-standing cocaine use.3 Cocaine causes coronary vasoconstriction through an alpha-adrenergic mechanism, which can be reversed by the intracoronary administration of phentolamine, an alpha-adrenergic antagonist.4 We report the use of intravenous phentolamine for the treatment of cocaine-induced myocardial ischemia.

A 38-year-old man presented to the emergency department because of substernal chest pain and dyspnea that had been present for two hours. He had insufflated cocaine two hours before the onset of the chest pain. Two years earlier he had had a myocardial infarction attributed to cocaine use. Cardiac catheterization at that time showed normal coronary arteries. On arrival, the patient was anxious and tremulous. The blood pressure was 140/84 mm Hg, the heart rate 120 beats per minute, the respiratory rate 20 per minute, and the temperature 98.2°F. The remainder of the physical examination was normal. An electrocardiogram showed sinus tachycardia, a normal axis and intervals, and ST-segment elevations of 1 to 2 mm in Leads V₂ through V₄. The patient was treated with 100 percent oxygen and was given a total of 20 mg of diazepam intravenously for his agitation. Aspirin and sublingual nitroglycerin did not relieve his pain. After 1 mg of phentolamine was given intravenously, the chest pain decreased in intensity during the subsequent minute; the blood pressure, heart rate, and electrocardiogram did not change. Because the chest pain persisted, an additional 1 mg of phentolamine was given intravenously seven minutes later, after which the pain resolved. Electrocardiography performed seven minutes later revealed near-normalization of the ST-segment elevations in Leads V₂ and V₄ but persistent ST elevation in Lead V₃. Subsequent measurements of cardiac enzymes and electrocardiograms revealed no evidence of myocardial infarction.

Phentolamine is a potent alpha-adrenergic—receptor antagonist used predominantly in hypertensive emergencies for its profound effects in lowering blood pressure. Although it has been found experimentally to reverse the coronary vasoconstriction and myocardial ischemia induced by cocaine,4 it has not been evaluated as a treatment for cocaine-induced myocardial ischemia. We recommend that the use of phentolamine for the treatment of cocaine-induced myocardial ischemia be evaluated further.

Judd E. Hollander, M.D.
Wallace A. Carter, M.D.
Bronx Municipal Hospital Center, Bronx, NY 10461

Robert S. Hoffman, M.D.
New York City Poison Control Center, New York, NY 10016

4 References

1. 1

   Coleman DL, Ross TF, Naughton JL. Myocardial ischemia and infarction related to recreational cocaine use . West J Med 1982;136:444–6.
   Medline

2. 2

   Minor RL Jr, Scott BD, Brown DD, Winniford MD. Cocaine-induced myocardial infarction in patients with normal coronary arteries . Ann Intern Med 1991;115:797–806.
   Web of Science | Medline

3. 3

   Hollander JE, Hoffman RS. Cocaine-induced myocardial infarction: an analysis and review of the literature . J Emerg Med 1992;10:169–77.
   CrossRef | Medline

4. 4

   Lange RA, Cigarroa RG, Yancy CW Jr, et al. Cocaine-induced coronary-artery vasoconstriction . N Engl J Med 1989;321:1557–62.
   Full Text | Web of Science | Medline

Citing Articles (12)

Citing Articles

1. 1

   J. B. Finkel, G. D. Marhefka. (2011) Rethinking Cocaine-Associated Chest Pain and Acute Coronary Syndromes. Mayo Clinic Proceedings 86:12, 1198-1207
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2. 2

   Robert S. Hoffman. (2010) Treatment of patients with cocaine-induced arrhythmias: bringing the bench to the bedside. British Journal of Clinical Pharmacology 69:5, 448-457
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   Judd E. Hollander. (2008) Cocaine Intoxication and Hypertension. Annals of Emergency Medicine 51:3, S18-S20
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   Andrew R. Haas, Paul E. Marik. (2006) CRITICAL CARE ISSUES FOR THE NEPHROLOGIST: Current Diagnosis and Management of Hypertensive Emergency. Seminars in Dialysis 19:6, 502-512
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   2006. Cocaine. , 848-879.
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   James H. Jones, William B. Weir. (2005) Cocaine-Associated Chest Pain. Medical Clinics of North America 89:6, 1323-1342
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   Joel T. Levis, Gus M. Garmel. (2005) Cocaine-Associated Chest Pain. Emergency Medicine Clinics of North America 23:4, 1083-1103
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8. 8

   Babak Mokhlesi, Thomas Corbridge. (2003) Toxicology in the critically ill patient. Clinics in Chest Medicine 24:4, 689-711
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9. 9

   R HOFFMAN, J HOLLANDER. (1997) EVALUATION OF PATIENTS WITH CHEST PAIN AFTER COCAINE USE. Critical Care Clinics 13:4, 809-828
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10. 10

    J Hollander. (1996) Complications from the use of thrombolytic agents in patients with cocaine associated chest pain. Journal of Emergency Medicine 14:6, 731-736
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11. 11

    Robert S Hoffman, Judd E Hollander. (1996) Thrombolytic therapy and cocaine-induced myocardial infarction. The American Journal of Emergency Medicine 14:7, 693-695
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12. 12

    Chui-Chung Tseng, Robert W. Derlet, Timothy E. Albertson. (1993) Acute cocaine toxicity: The effect of agents in non-seizure-induced death. Pharmacology Biochemistry and Behavior 46:1, 61-65
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