Cocaine-Induced Chest Pain with High CK: Is it due to MI or Rhabdomyolysis?

Author: V. Dimov, M.D., Cleveland Clinic
Reviewer: A. Aneja, M.D., Cleveland Clinic

A 47 yo AAM with a PMH of HTN, smoking and cocaine abuse is admitted to the hospital with CC: chest pain (CP), which started 50 minutes after his last dose of crack cocaine.

The patient was on a cocaine binge for the last 3 days, wondering on the streets and using all the cocaine he could buy. He had one episode of similar CP 2 years ago, again after using cocaine.

Physical examination
Sleepy but arousable, oriented x 3
BP 177/101, otherwise the examination is unremarkable.

What do you think is going on?
Cocaine-induced CP vs. CAD due to atherosclerosis

We have to take a look at his risk factors for CAD.

What labs would you order?
Cardiac enzymes x 2 q 8 hrs. Cardiac enzymes include CK, CK-MB and troponin.
EKG now and in 6-8 hrs
CBC, CMP, FLP (fasting lipid profile)

It is important to remember that when you "rule out" a patient for MI, you not only order labs but you also start treatment at the same time.

The patient was given ASA, O2, Nitro SL and Metoprolol (before he told the ER doctor that he had used cocaine). He was CP-free after admission. Urine toxic screen was positive for cocaine.

There were nonspecific changes on the EKG.


CBC, CMP, cardiac enzymes, FLP (click to enlarge)

CK came back more than 1800, CK-MB was 14 (high) and troponin was negative.

What do you think?
Is it AMI? Not likely -- troponin has 97% sensitivity and specificity. A negative troponin virtually rules out AMI.

What is the reason for the elevated CK then?
Rhabdomylosis. Cocaine, as well as PCP, can cause rhabdomyolysis

What happened?
The patient was given NS IV at 200 cc/hr to maintain a good urine output. CK decreased to 300 two days later, and he was discharged after seeing a drug abuse counselor. Cardiac enzymes x 2 q 8 hrs were negative for AMI, and he continued to be CP-free

What did we learn from this case?
Rhabdomylosis is a known complication of cocaine use.

Always take the cocaine-induced CP seriously because this patient might just be the one with a true MI, and you do not want to miss it.

Cocaine Abuse Q&A

How accurate is the cocaine urine test?
Over 95% accurate.

How long does cocaine and other drugs stay in the urine?
Cannabinoids (THC, marijuana) - 20-90 days. Cocaine (crack) - 3-5 days. Phencyclidine (PCP, angel dust) - 1-30 days, single use: 1-7 days, regular use : up to 30 days. Opiates (heroin, Vicodin, morphine, codeine) - 2-7 days.

When to discharge a patient with rhabdomyolysis? Is there a specific CK level which is safe for D/C?
Rhabdomyolys is is defined by a serum CK level of more than 1,000 U/L (more than five-fold that of normal). A patient who can maintain a good PO intake of fluids can be discharged home if the level of CK is less than 1000.

How often do we see rhabdomyolysis in cocaine users?
About 24% of the cocaine users develop rhabdomyolysis. In one study, patients' mean CK level was 12,000 (range, 1756 to 85,000), 33 percent of the patients had acute renal failure.

References
Cocaine chest pain. Emerg Med Clin North Am. 1994 May;12(2):391-6.
Cocaine-associated Chest Pain. How Common Is Myocardial Infarction? Academic Emergency Medicine Volume 7, Number 8 873-877.

Further reading
Cocaine FOR Chest Pain
Images in Medicine: Visualising rhabdomyolysis with Tc 99 -labelled diphosphonate bone scan. The Lancet, 01/2009.
Rhabdomyolysis Review, Hospital Physician, 2009 (PDF).

Published: 04/11/2005
Updated: 05/09/2009