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Aspirin
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Aspirin and lorazepam
Aspirin and metoprolol
Aspirin, lorazepam, and metoprolol
Lorazepam and metoprolol
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This patient with sweaty skin, dilated pupils, chest pain, dyspnea, and ST elevations on ECG most likely has a myocardial infarction caused by cocaine use. Given his acute cocaine use, aspirin and lorazepam are the most appropriate treatment at this time.Cocaine is a sympathomimetic that causes tachycardia, diaphoresis, hypertension, and vasospasm. Vasospasm of the coronary arteries can lead to an acute STEMI, which presents with chest pain, dyspnea, diaphoresis, and radiation of pain to the arms, jaw, or abdomen. Cocaine also has prothrombotic properties thus increasing the risk of STEMI. The acute management of a STEMI with cocaine use is the same as for any STEMI including aspirin, a second antiplatelet agent, heparin, and cardiac catheterization. Beta-blockers are avoided in the management of cocaine-induced STEMI or hypertension as they cause unopposed alpha-1 activity. This results in worsening vasospasm leading to hypertension and decreased perfusion to the area of ischemic myocardium. Benzodiazepines can be given to lower blood pressure and possibly relieve vasospasm.Sen et al. reviewed the evidence regarding the diagnosis and treatment of STEMI in patients who use cocaine. They discuss how beta-blockers can cause a hypertensive crisis due to unopposed alpha activity. They recommend avoiding these agents in patients suspected of cocaine use.Figure/Illustration A is an ECG demonstrating ST elevation in the frontal leads (red circle). This finding is characteristically seen in a STEMI.Incorrect Answers:Answer 1: Aspirin is the preferred initial antiplatelet agent for any patient presenting with chest pain that is concerning for acute coronary syndrome unless the patient has a history of aspirin allergy. Patients should also get a benzodiazepine because it reduces sympathetic outflow by acting at the GABAa receptor. It may therefore reduce blood pressure and could improve symptoms of vasospasm.Answers 3-5: Beta-blockers are avoided in the management of cocaine-induced STEMI or hypertension as they cause unopposed alpha-1 activity. This results in worsening vasospasm leading to hypertension and decreased perfusion to the area of ischemic myocardium. Instead, benzodiazepines can be given to lower blood pressure and possibly relieve vasospasm.Bullet Summary:Acute coronary syndrome associated with cocaine use is managed with aspirin, benzodiazepines, and avoidance of beta-blockers which can cause hypertensive crisis.
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