Episodic cocaine use leads to short-lived states of autonomic arousal. Chronic use can lead to scarring of heart tissue and myocardial hypertrophy and other changes collectively known as myocardial remodelling. These changes constitute the substrate for the occurrence of lethal arrhythmias.
Cocaine binds to the hERG (rapid repolarising potassium) channel, disrupting the normal process of depolarisation in heart muscle. Cocaine should not, therefore, be used concomitantly with drugs known to cause QT interval prolongation.
While chest pain related to cocaine use is a common reason for seeking medical care, occasional use is rarely associated with acute myocardial infarction (AMI) unless there is pre-existing coronary artery disease.
Psychosis can be seen in chronic users as an isolated condition or as a feature of 'excited delirium'. It is an agitated confusional state associated with potentially lethal hyperthermia.
There is no evidence to support the use of antipsychotic agents for cocaine dependence. Antipsychotic agents may cause QT interval prolongation and, when used concomitantly with cocaine, may compound the risk of sudden death.
Cocaine is a drug of abuse that is usually either insufflated (snorted), injected, or smoked in its freebase form (crack). Cocaine is a type IA antidysrhythmic, local anaesthetic, and sympathomimetic. It can also bind the hERG (slowly depolarising inward potassium channel), which is prodysrhythmic.
History and exam
- anxiety (panic state: mild to severe)
- drug-induced formication
- previous hospitalisation for detoxification
- suspicion of body packing (swallowing drug packets for transport)
- suspicious burns (e.g., crack lip, crack thumb)
- nasal septum ulceration, perforation
- focal neurological abnormalities
- seizure activity
- loss of consciousness/altered consciousness
- skin lesions (e.g., subcutaneous salmon-coloured patches, infections, erosions, necrosis)
Steven B. Karch, MD, FFFLM, FCSFS
Consultant Cardiac Pathologist/Toxicologist (ret.)
Office of the Chief Medical Examiner
SBK is an author of a number of references cited in this monograph. SBK declares that he has no other competing interests.
Timothy Albertson, MD, PhD, MPH
Division of Pulmonary and Critical Care Medicine
University of California, Davis
TA declares that he has no competing interests.
Andrew Stolbach, MD
Department of Emergency Medicine
Johns Hopkins University Hospital
AS declares that he has no competing interests.
Russel Falck, MA
Assistant Professor of Community Health and Associate Director
Center for Interventions
Treatment and Addictions Research
Wright State University Boonshoft School of Medicine
RF declares that he has no competing interests.
Christos Kouimtsidis, MBBS, MSc, MRCPsych, PhD
Consultant Psychiatrist and Honorary Senior Lecturer
Addictions, Alcohol Research
Institute of Psychiatry
King's College London
CK declares that he has no competing interests.
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