Cocaine-Associated ST-Elevation Myocardial Infarction: Different Pathophysiological Mechanisms

J INVASIVE CARDIOL 2019;31(4):E62-E63.

Key words: angiography, cardiac imaging, cocaine-associated myocardial infarction, optical coherence tomography

The incidence of cocaine-associated myocardial infarction (CAMI) varies from 0.7%-6.0%. The pathophysiology of CAMI is complex. Cocaine has been found to promote endothelial dysfunction; to increase vascular permeability, platelet aggregation, and thrombosis; to accelerate atherosclerosis with partially calcified unstable plaques; and to increase endothelial shear stress, leading to rupture, coronary artery vasospasm, and increased oxygen demand.

We describe a 26-year-old-man with no previous medical history, who suddenly collapsed. He was a cocaine user and had inhaled 2.5 g cocaine about 2 hours before the episode, which was confirmed with positive urine toxicology. Emergency services started on-site cardiopulmonary resuscitation shortly thereafter. A 12-lead electrocardiogram showed anterior ST-segment elevation (Figure 1A). After stabilization, he was transferred for primary angioplasty. Coronary angiography showed a total occlusion of the proximal left anterior descending (LAD) coronary artery (Figure 1B). We gently advanced a guidewire into the LAD without recovery of distal flow. As we suspected large thrombus burden, we performed thrombus aspiration. Although no macroscopic thrombus was retrieved, TIMI 2 flow was achieved. A confined lumen narrowing filling defect in the proximal segment of the LAD was then observed (Figure 1C). This coronary narrowing remained similar after intracoronary nitroglycerin administration. Optical coherence tomography (OCT) showed an intimomedial dissection with an intimal tear at the edge with red thrombus between the false lumen and true lumen that was partially collapsed (Figure 1D). A drug-eluting stent was then implanted with excellent result (Figure 1E).

There are many underlying mechanisms for CAMI, and the culprit has to be elucidated for appropriate therapeutic management. OCT provides unique insights when angiography alone has limited diagnostic value. OCT also aids in the decision between conservative management and revascularization strategy and guides coronary interventions.

From the University General Hospital of Ciudad Real, Real, Spain.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted October 31, 2018.

Address for correspondence: Maria T. López-Lluva, MD, University General Hospital of Ciudad Real, Calle Obispo Rafael Torija, s/n, 13005 Ciudad Real, Cdad, Real, Spain. Email: mtl.lluva@gmail.com