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What's the skinny on cocaine and heart attacks?

August 16, 2008

Matthew Vasey, MD



An incomplete list of street names for cocaine include: All-American Drug, Aunt Nora, Barbs, Bazulco, Beam, Bernie, Billie Hoke, Blanca, Blow, Bolivian Marching Powder, Chippy, Choe, Coca, Coconut, Coke, Devil's Dandruff, Flake, Foo Foo, Friskie Powder, Gold Dust, Happy Dust, Henry VIII, Ice, Lady Caine, Line, Nose Candy, Oyster Stew, Pimp, Scottie, Snow White, Star-Spangled Powder and Zip to name a few. (5) For a complete list, we will defer to the neighborhood street pharmacist although we do not recommend consulting them for this information. Cocaine represents a dangerous drug for a multitude of reasons but most importantly for the purposes of this article because of the propensity to cause a heart attack, or indirectly, congestive heart failure. Sadly, I know, almost as cliche as saying cigarette smoking causes lung cancer.

The American Heart Association recently made a scientific statement based on their findings from a review of the medical literature on the topic of cocaine associated chest pain and myocardial infarction or heart attack. Cocaine is the second most commonly used illicit drug in the United States behind that devil's lettuce known as marijuana. (4) Cocaine is the illicit drug most likely to land you in the Emergency Room. (7) They estimate about 14% of people over the age of 12 have given coke a try at least once. (8)

I asked a few friends if they knew what exactly happened in a "heart attack". There answers were not so hot, thence an explanation is warranted. Basically, there are a series of blood vessels that wrap around the surface of your heart called coronary arteries. They stem from just two, the right and left coronary artery. These are the vessels that supply oxygenated blood to your heart, a muscle, so it can squeeze and circulate blood throughout your body. In a heart attack, or myocardial infarction these vessels get clogged for whatever reason (clot, spasm, etc...) so not enough oxygenated blood can make it through so the part of the heart supplied by that particular vessel, dies. Depending on where the clog is and how much muscle is usually supplied with oxygen beyond or distal to the clog is how severe the heart attack presents. This can result in immediate death because a large part of the heart is dead and can't pump so in turn the body dies soon after, as was the case with the publicised death of Tim Russert the NBC broadcaster who recently died from a heart attack.

Not all heart attacks are fatal but they do add up because they reduce the effectiveness of the hearts ability to pump leading to heart failure, our nation's single most expensive illness. More money is spent treating heart failure than any other medical illness. Heart attacks also create an area of dead muscle in the heart which greatly increases the likelihood of deadly arrhythmia. Arrhythmias are difficult to explain but essentially there is electrical current that flows through the heart muscle from top to bottom controlling the speed of squeezes that the heart does. When there is dead tissue this electrical current can more easily get out of whack and can cause your heart to stop beating, translation, R.I.P.

So looking specifically at cocaine, the way in which it causes a heart attack is due to a couple reasons:
1. Cocaine makes the heart scream for oxygenated blood. It increases the oxygen demand of the heart by increasing the number of squeezes the heart makes, the strength of the squeeze and your bodies' blood pressure. (6)
2. Cocaine makes the coronary vessels constrict and therefore reduces the amount of oxygenated blood that can make it to the heart. Supply is not meeting demand and this gets worse and worse until the heart attack occurs. (6) In the event the cocaine wears off without causing a heart attack, the next time cocaine is used the gamble of supply and demand mismatch of oxygenated blood starts up again. It is foolish to think that there is a safe amount of cocaine to use given points #3, #4, the obvious variability in measurements and production.
3. Cocaine causes changes in the blood making it more likely to clog up your vessels. (6)
4. Cocaine accelerates atherosclerosis which is an accumulation of crud for lack of better word that resembles crunchy, mashed French fry that builds up on the inside of the coronary arteries narrowing them making for reduced flow of blood to the heart muscle. (6)

People showing up the Emergency Room with complaints of chest pain related to cocaine use end up having had a heart attack 6% of the time.(1) The word pain is used to represent chest discomfort or pressure, not exactly pain per say. The average age of heart attack was 38 which may seem ancient to the young and healthy readers of NYJSM.com but from a medical stand point, 38 is alarmingly young. (3) So how long after a cocaine binge do heart attacks occur? Well, one study showed two-thirds of heart attacks occurred within 3 hours of cocaine, but can occur anywhere from 1 minute to 4 days (2). While I suspect cocaine use will continue despite the self-proclaimed landmark publication of "What's the skinny on cocaine and heart attacks?" Perhaps the next time someone you love is rolling snow men with their nose you can shout "halt" like Eddie Murphy in Coming to America with your arm elevated and share your expertise on cocaine associated myocardial infarction as learned from the New York Journal of Style and Medicine.

References:
1. Hollander J, Hoffman R, Genni P, et al. Prospective multicenter evaluation of cocaine-associated chest pain. Cocaine associated chest pain (COCHPA) study group. Acad Emerg Med. 1994;1:330-339.
2. Hollander J, Hoffman R. Cocaine-induced mycocardial infaction: an analysis and review of the literature. J Emerg Med. 1992;10:169-177.
3. Hollander J, Hoffman R, Gennis P, et al. Cocaine -associated chest pain: one-year follow-up. Acad Emerg Med. 1995;2:179-184.
4. Hughes, A, Sathe, N, Spangnola, K. State estimates of substance use from the 2005-2006 national surveys on drug use and health. DHHS Publication NO. SMA 08-4311, NSDUH Series H-33. Rockville, Md: Substance abuse and mental health service administration, Office of Applied Studies; 2008.
5. http://crack-cocaine.org
6. McCord J, Jneid H, Hollander J, et al. Management of cocaine-associate chest pain and myocardial infarction. Circulation. 2008;117:1897-1907.
7. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Emergency deparment trends from the drug abuse warning network, final estimates 1995-2002. DAWN Series: D-24, DHHS Publication No. (SMA) 03-3780. Fockville, MD: US Department of Health and Human Services; 2003.
8. Substance Abuse and Mental Health Services Adminstration, Office of Applied Studies. Results from the 2004 national survey on drug use and health: national findings. NSDUH Series H-28, DHHS Publication No. SMA05-4062 Fockville, MD: US Department of Health and Human Services; 2005.
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