Correspondence
Cocaine-Induced Coronary-Artery Dissection
N Engl J Med 1994; 330:510-511February 17, 1994
- Article
To the Editor:
Cocaine abuse has been associated with myocardial injury, infarction, and dysfunction caused by a number of mechanisms, including coronary vasospasm, thrombotic coronary occlusion, and marked systemic hypertension1. We report a case of acute coronary-artery dissection and consequent myocardial ischemia and infarction after cocaine use.
A 27-year-old previously healthy man presented to a local emergency room after having 45 minutes of substernal chest pain radiating to both scapulas, nausea, and diaphoresis. The pain followed nasal inhalation of cocaine for 2 to 3 hours and began 10 to 15 minutes after the man smoked “crack” cocaine. An electrocardiogram showed T-wave inversion in leads II, III, and aVF, and within eight hours the serum creatine kinase concentration rose to 894 U per liter (normal, <250), with a 17 percent MB fraction. Cardiac catheterization and angiography, performed the next morning, demonstrated normal intracardiac pressures, inferior-wall hypokinesis (on left ventriculography), and extensive dissection of the middle-to-distal portions of the right coronary artery (Figure 1Figure 1
Dissection Involving the Middle-to-Distal Portions of the Right Coronary Artery (Arrows) on Selective Angiography (Right Anterior Oblique View).). The patient underwent urgent, single-vessel bypass grafting of the saphenous vein to the distal right coronary artery and recovered without further complication. One year later (while in prison) he presented with atypical chest pain at a state university medical center. Repeat cardiac catheterization and angiography demonstrated a stable, chronic dissection of the middle of the right coronary artery, with good flow to distal segments. The single-vein graft was occluded.The clinical presentation and laboratory studies strongly suggest a mechanistic link between the cocaine use, the coronary-artery dissection, and the ischemia and infarction of the myocardial region supplied by the disrupted artery. Myocardial injury, infarction, and dysfunction have been attributed to the action of cocaine through a variety of pathophysiologic mechanisms and events1. This report adds cocaine-induced coronary-artery dissection to the long list of cardiovascular complications of cocaine abuse. Aortic dissection and rupture have been reported to follow cocaine use2-4. Cocaine-induced systemic hypertension has been proposed as the chief predisposing factor, because none of the patients described had evidence of a connective-tissue disorder, congenital heart disease, or prior aortic disease. Our patient had no clinical or laboratory evidence of aortic dissection.
Isolated coronary-artery dissection is most commonly caused by trauma (closed chest or penetrating), coronary angiography, angioplasty, or surgery and can be a complication of the Marfan syndrome and, rarely, pregnancy5. The coronary dissection in our patient could not be attributed to any of these conditions but was closely associated with heavy self-administration of cocaine. Coronary-artery dissection is yet another consideration in the differential diagnosis of chest pain and myocardial ischemia and infarction in the cocaine abuser.
5 ReferencesBrian D. Jaffe, M.D.
Ohio State University College of Medicine, Columbus, OH 43210Thomas M. Broderick, M.D.
Christ Hospital, Cincinnati, OH 45219Carl V. Leier, M.D.
Ohio State University College of Medicine, Columbus, OH 432101
Isner JM ,Estes NAM III ,Thompson PD , et al. Acute cardiac events temporally related to cocaine abuse. N Engl J Med 1986;315:1438-1443
Full Text | Web of Science | Medline2
Barth CW III ,Bray M ,Roberts WC . Rupture of the ascending aorta during cocaine intoxication. Am J Cardiol 1986;57:496-496
CrossRef | Web of Science | Medline3
Gadaleta D ,Hall MH ,Nelson RL . Cocaine-induced acute aortic dissection. Chest 1989;96:1203-1205
CrossRef | Web of Science | Medline4
Om A ,Porter T ,Mohanty PK . Transesophageal echocardiographic diagnosis of acute aortic dissection complicating cocaine abuse. Am Heart J 1992;123:532-534
CrossRef | Web of Science | Medline5
Thayer JO ,Healey RW ,Maggs PR . Spontaneous coronary artery dissection. Ann Thorac Surg 1987;44:97-102
CrossRef | Web of Science | Medline
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Benjamin Hunt, Roderick Chua, Nicholas Bett. (2010) Conservative Treatment of Spontaneous Dissection of Multiple Coronary Arteries. Heart, Lung and Circulation 19:11, 678-680
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Ersan Tatli, Armagan Altun. (2010) May emergency hypertension be reason of spontaneous coronary artery dissection?. International Journal of Cardiology 140:3, e53-e54
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Alessandro Fontanelli, Zoran Olivari, Luigi La Vecchia, Cristina Basso, Leopoldo Pagliani, Antonio Marzocchi, Piero Zonzin, Corrado Vassanelli, Francesco Di Pede. (2009) Spontaneous dissections of coronary arteries and acute coronary syndromes: rationale and design of the DISCOVERY, a multicenter prospective registry with a case–control group. Journal of Cardiovascular Medicine 10:1, 94-99
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Natale Daniele Brunetti, Pier Luigi Pellegrino, Giovanni Mavilio, Andrea Cuculo, Luigi Ziccardi, Michele Correale, Matteo Di Biase. (2007) Spontaneous coronary dissection complicating unstable coronary plaque in young women with acute coronary syndrome: Case reports. International Journal of Cardiology 115:1, 105-107
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M. Cruz Ferrer-Gracia, Raúl Moreno, Rosa A. Hernández-Antolín, Carlos Macaya. (2006) Insuficiencia mitral transitoria asociada a disección coronaria espontánea. Medicina Clínica 126:18, 718-719
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Ilias Karabinos, Anastasios Papadopoulos, Spyridon Koulouris, Athanasios Kranidis, Socrates Korovesis, Demosthenes Katritsis. (2006) Spontaneous Coronary Artery Dissection during a Dobutamine Stress Echocardiography. Echocardiography 23:3, 232-234
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Corrado Vassanelli. (2006) Spontaneous coronary artery dissection: when spontaneous means unknown. Journal of Cardiovascular Medicine 7:1, 71-73
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Nazim Uddin Azam Khan, Michael J. Miller, Joseph D. Babb, Sagir Ahmed, Pabitra K. Saha, Rony L. Shammas, Robert G. Macdonald, Assad Movahed. (2006) Spontaneous coronary artery dissection. Acute Cardiac Care 8:3, 162-171
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Yuko Ueda, Toshihide Hinoi, Shusuke Matsuo, Futoshi Tadehara, Shuji Tsujiyama, Tetsuya Ono, Michio Yamakido. (2006) Intravascular Ultrasound-Guided Coronary Artery Stenting for Spontaneous Coronary Artery Dissection in a Case of Acute Myocardial Infarction Associated with Vasospasm in a Non-Culprit Coronary Artery during the Hospitalization. Internal Medicine 45:12, 763-767
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2006. Cocaine. , 848-879.
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Seshasayee Narasimhan. (2004) Spontaneous coronary artery dissection (SCAD). Indian Journal of Thoracic and Cardiovascular Surgery 20:4, 189-191
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Francis Q. Almeda, Sameer Barkatullah, Clifford J. Kavinsky. (2004) Spontaneous coronary artery dissection. Clinical Cardiology 27:7, 377-380
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Joseph S. Alpert. (2004) Spontaneous coronary artery dissection: An uncommon but dangerous condition. Current Cardiology Reports 6:4, 233-234
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Cristian Palmiere, Sandra Burkhardt, Christian Staub, Myriam Hallenbarter, Gian Paolo Pizzolato, Reinhard Dettmeyer, Romano La Harpe. (2004) Thoracic aortic dissection associated with cocaine abuse. Forensic Science International 141:2-3, 137-142
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Raed A. Aqel, Gilbert J. Zoghbi, Ami Iskandrian. (2004) Spontaneous Coronary Artery Dissection, Aneurysms, and Pseudoaneurysms: A Review. Echocardiography 21:2, 175-182
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Rajko Kavalar, Ivan Krajne. (2003) Spontaneous dissecting aneurysm of the coronary artery. Wiener Klinische Wochenschrift 115:10, 347-350
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Raghunandan Kamineni, Ashish Sadhu, Joseph S. Alpert. (2002) Spontaneous Coronary Artery Dissection: Report of Two Cases and a 50-Year Review of the Literature. Cardiology in Review 10:5, 279-284
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George A. Stouffer, Richard G. Sheahan, Daniel J. Lenihan, Michael B. Erwin, Efthymios N. Deliargyris. (2002) Cocaine-Associated Chest Pain. The American Journal of the Medical Sciences 324:1, 37-44
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Khalid E Eskander, Neil S Brass, Elliot T Gelfand. (2001) Cocaine abuse and coronary artery dissection. The Annals of Thoracic Surgery 71:1, 340-341
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Peter R. Vale, David W. Baron. (1998) Coronary artery stenting for spontaneous coronary artery dissection: A case report and review of the literature. Catheterization and Cardiovascular Diagnosis 45:3, 280-286
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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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