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-year-old African American male (AAM) with a past medical history (PMH) of hypertension (HTN), smoking and cocaine abuse is admitted to the hospital with a chief complaint (CC) of 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 is the most likely diagnosis?

Cocaine-induced CP vs. CAD due to atherosclerosis

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

What laboratory workup would you suggest?
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 the images).

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.

Related 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).
Among patients with suspected ACS, hsTnI or cTnI determination 3 hours after admission may help to rule-out AMI - JAMA, 2011.

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

5 comments:

  1. Most of the males between ages 18-40 admitted with cocaine induced chest pain, final diagnosis is rhabdo.On our unit,as a rule of thumb we take all chest pain seriously just as you have said. But, once the (troponin)cardiac enzymes come back negative we then rule out acute MI.Sometimes we call the doctor to discontinue the telemetry order. Should we wait until discharge?

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  2. Rhabdomyolysis Review, Hospital Physician, 2009 (PDF). After reading this article am I to understand Rhabdo can start within 2 hours of injury or injestion of toxins ? Or is the onset immediate? I'm clear on the process but unclear on the start. We have alot of alcoholics that experiment with drugs and aren't always honest and forthcoming. They come so frequently that symptoms are sometimes not explored.I just wonder if we are overlooking possibility of Rhabdo?

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  3. Rhabdomyolysis is common in cases of prolonged prostration - for example, unconscious patients from any reason or those who fall and cannot get up (elderly).

    I would say, it takes at least a few hours to develop rhabdo unless we talk about crushing rhabdo as is the case with trauma - e.g. victims of earthquake, vehicle accidents, etc.

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  4. Thanks for your response. This helps me to decide on levels of diagnostic testing needed or not needed for these chronic patients.

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