eMedicine Specialties > Cardiology > Myocardial Disease and Cardiomyopathies

Cardiomyopathy, Cocaine: Differential Diagnoses & Workup

Author: Michal Kazimir, MD, Staff Physician, Department of Internal Medicine, Lehigh Valley Hospital
Coauthor(s): Paul A Janson, MD, Instructor, Tufts University School of Medicine; Director, EMT/RN Consultants; Consulting Staff, Department of Emergency Medicine, Lawrence General Hospital; James V Talano, MD, MM, FACC, Director of Cardiovascular Medicine, SWICFT Institute; Carla Vaccaro, MD, Consulting Staff, Department of Family Practice, Merrimack Family Medicine
Contributor Information and Disclosures

Updated: Mar 24, 2008

Differential Diagnoses

Amphetamine-Related Psychiatric Disorders
Cardiomyopathy, Hypertrophic
Aortic Dissection
Cardiomyopathy, Peripartum
Cardiogenic Shock
Coronary Artery Vasospasm
Cardiomyopathy, Alcoholic
Myocarditis
Cardiomyopathy, Diabetic Heart Disease
Pheochromocytoma
Cardiomyopathy, Dilated
Pulmonary Edema, Cardiogenic

Workup

Laboratory Studies

  • Chem 7: The laboratory investigation of cardiomyopathy of any etiology generally shows abnormalities of electrolytes and compromised renal function with elevation of BUN and creatinine.
  • Urine toxicology: Cocaine usually is evident on a urine toxicology screen because these cases almost always present immediately after use of the drug.
  • Blood cultures: Because individuals who use cocaine are predisposed to the development of endocarditis, consider blood cultures if the setting is at all appropriate.

Imaging Studies

  • Chest radiograph: In cases of cardiomyopathy, the chest radiograph usually shows evidence of cardiomegaly and congestive heart failure. Evidence of septic emboli may be present if endocarditis is present. The radiograph may be normal in many cases.
  • Echocardiographic evaluation shows chamber dilation and global dysfunction or regional wall motion abnormalities if myocardial infarction is present.
  • Echocardiographic studies show that individuals who abuse cocaine have increased left ventricular mass index with a higher tendency toward increased posterior wall thickness.
  • Cardiac catheterization usually shows normal coronary arteries or only minimal disease, even in the presence of myocardial infarction.
  • Head CT/MRI: Ischemic stroke is seen in highest frequency in the first few hours after taking cocaine, likely due to thrombogenic effect via platelet activation. However, stroke onset may be delayed as long as one week, possibly due to the formation of longer-acting secondary metabolites. Cerebral atrophy is a known feature of chronic cocaine use.

Other Tests

  • ECG: In acute chest pain syndromes, the ECG may show evidence of acute ischemia or infarction. In cases of cardiomyopathy, the ECG is not specific but may show evidence of left ventricular hypertrophy and nonspecific ST-T wave changes. Arrhythmias also may be detected, and continuous monitoring may be advisable.

Procedures

  • Pulmonary artery line placement: Because many of these patients are in shock and because appropriate fluid management is difficult in this setting, a pulmonary artery line frequently is placed.
  • Arterial line placement: An arterial line may be placed in order to adequately manage blood pressure.
  • Intra-aortic balloon placement: The use of an intra-aortic balloon has been described, in order to bridge the gap until cardiac function can improve.

Histologic Findings

Chokshi was one of the first authors to describe a reversible cocaine-induced cardiomyopathy. His patient, a 35-year-old woman, underwent endomyocardial biopsy that failed to reveal any necrosis, fibrosis, or inflammatory infiltrate.5

Virmani autopsied 40 patients who died traumatic deaths with cocaine and found that 20% of those patients showed evidence of myocarditis on toxic screening tests, and an eosinophilic infiltrate was observed.6

Tazelaar, in an autopsy study, reported contraction based myocardial necrosis similar to that observed in pheochromocytoma.7

In a case report by Robledo-Carmona, histologic findings of left ventricle myocardium included sparse mononuclear infiltrates associated with degenerative changes, myocyte necrosis, and severe interstitial fibrosis.8

More on Cardiomyopathy, Cocaine

Overview: Cardiomyopathy, Cocaine
Differential Diagnoses & Workup: Cardiomyopathy, Cocaine
Treatment & Medication: Cardiomyopathy, Cocaine
Follow-up: Cardiomyopathy, Cocaine
References
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References

  1. Isabelle M, Vergeade A, Moritz F, Dautreaux B, Henry JP, Lallemand F, et al. NADPH Oxidase Inhibition Prevents Cocaine-Induced Up-Regulation of Xanthine Oxidoreductase and Cardiac Dysfunction. J Mol Cell Cardiol. 2007;42:326-332. [Medline].

  2. US Department of Health and Human Services. Substance Abuse and Mental Health Services Administration, Results from the 2005 National Survey on Drug Use and Health: National Findings. September 2006;[Full Text].

  3. Felker GM, Hu W, Hare JM. The spectrum of dilated cardiomyopathy. The Johns Hopkins experience with 1,278 patients. Medicine (Baltimore). Jul 1999;78(4):270-83. [Medline].

  4. Bertolet BD, Freund G, Martin CA. Unrecognized left ventricular dysfunction in an apparently healthy cocaine abuse population. Clin Cardiol. 1990;May;13(5):323-8.

  5. Chokshi SK, Moore R, Pandian NG. Reversible cardiomyopathy associated with cocaine intoxication. Ann Intern Med. Dec 15 1989;111(12):1039-40. [Medline].

  6. Virmani R, Robinowitz M, Smialek JE, Smyth DF. Cardiovascular effects of cocaine: an autopsy study of 40 patients. Am Heart J. Jun 1989;117(6):1298-9. [Medline].

  7. Tazelaar HD, Karch SB, Stephens BG. Cocaine and the heart. Hum Pathol. Feb 1987;18(2):195-9. [Medline].

  8. Robledo-Carmona J, Ortega-Jimenez M, Garcia-Pinilla J, Cabra B, de Teresa E. Severe Cardiomyopathy Associated to Cocaine Abuse. Int J Cardiol. 2006;112:130-131. [Medline].

  9. Chakko S, Fernandez A, Mellman TA. Cardiac manifestations of cocaine abuse: a cross-sectional study of asymptomatic men with a history of long-term abuse of "crack" cocaine. J Am Coll Cardiol. Nov 1 1992;20(5):1168-74. [Medline].

  10. Chakko S, Myerburg RJ. Cardiac complications of cocaine abuse. Clin Cardiol. Feb 1995;18(2):67-72. [Medline].

  11. Chambers HF, Morris DL, Tauber MG. Cocaine use and the risk for endocarditis in intravenous drug users. Ann Intern Med. 1987;106:833-6.

  12. Das G. Cardiovascular effects of cocaine abuse. Int J Clin Pharmacol Ther Toxicol. Nov 1993;31(11):521-8. [Medline].

  13. Duell PB. Chronic cocaine abuse and dilated cardiomyopathy [letter]. Am J Med. Sep 1987;83(3):601. [Medline].

  14. Hagan IG, Burney K. Radiology of Recreational Drug Abuse. Radiographics. 2007;27:919-940. [Medline].

  15. Henning RJ, Li Y. Cocaine produces cardiac hypertrophy by protein kinase C dependent mechanisms. J Cardiovasc Pharmacol Ther. Jun 2003;8(2):149-60.

  16. Hogya PT, Wolfson AB. Chronic cocaine abuse associated with dilated cardiomyopathy. Am J Emerg Med. May 1990;8(3):203-4. [Medline].

  17. Isner JM, Chokshi SK. Cardiac complications of cocaine abuse. Annu Rev Med. 1991;42:133-8. [Medline].

  18. Isner JM, Chokshi SK. Cocaine and vasospasm [editorial; comment]. N Engl J Med. Dec 7 1989;321(23):1604-6. [Medline].

  19. Kloner RA, Hale S, Alker K. The effects of acute and chronic cocaine use on the heart. Circulation. Feb 1992;85(2):407-19. [Medline].

  20. Lombard J, Levin IH, Weiner WJ. Arsenic intoxication in a cocaine abuser [letter]. N Engl J Med. Mar 30 1989;320(13):869. [Medline].

  21. Moliterno DJ, Lange RA, Gerard RD. Influence of intranasal cocaine on plasma constituents associated with endogenous thrombosis and thrombolysis. Am J Med. Jun 1994;96(6):492-6. [Medline].

  22. Mouhaffel AH, Madu EC, Satmary WA. Cardiovascular complications of cocaine. Chest. May 1995;107(5):1426-34. [Medline].

  23. Om A. Cardiovascular complications of cocaine. Am J Med Sci. May 1992;303(5):333-9. [Medline].

  24. Peng SK, French WJ, Pelikan PC. Direct cocaine cardiotoxicity demonstrated by endomyocardial biopsy. Arch Pathol Lab Med. Aug 1989;113(8):842-5. [Medline].

  25. Ren S, Tong W, Lai H. Effect of long-term cocaine use on regional left ventricular function as determined by magnetic resonance imaging. Am J Cardiol. Apr 1 2006;97(7):1085-8. [Full Text].

  26. Sadoshima J, Taira Y, Shimokawa H. Two cases of dilated cardiomyopathy complicated by left ventricular aneurysm. Chest. Aug 1987;92(2):377-9. [Medline].

  27. Sauer CM. Recurrent embolic stroke and cocaine-related cardiomyopathy. Stroke. Sep 1991;22(9):1203-5. [Medline].

  28. Shannon M. Clinical toxicity of cocaine adulterants. Ann Emerg Med. Nov 1988;17(11):1243-7. [Medline].

  29. Shannon RP, Lozano P, Cai Q. Mechanism of the systemic, left ventricular, and coronary vascular tolerance to a binge of cocaine in conscious dogs. Circulation. Aug 1 1996;94(3):534-41. [Medline].

  30. Wiener RS, Lockhart JT, Schwartz RG. Dilated cardiomyopathy and cocaine abuse. Report of two cases. Am J Med. Oct 1986;81(4):699-701. [Medline].

  31. Willens HJ, Chakko SC, Kessler KM. Cardiovascular manifestations of cocaine abuse. A case of recurrent dilated cardiomyopathy. Chest. Aug 1994;106(2):594-600. [Medline].

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Further Reading

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Keywords

cocaine cardiomyopathy, cocaine myocarditis, cocaine-induced heart failure, chronic cardiomyopathy, cocaine abuse, cocaine addiction

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Contributor Information and Disclosures

Author

Michal Kazimir, MD, Staff Physician, Department of Internal Medicine, Lehigh Valley Hospital
Michal Kazimir, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, and American Heart Association
Disclosure: Nothing to disclose.

Coauthor(s)

Paul A Janson, MD, Instructor, Tufts University School of Medicine; Director, EMT/RN Consultants; Consulting Staff, Department of Emergency Medicine, Lawrence General Hospital
Paul A Janson, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

James V Talano, MD, MM, FACC, Director of Cardiovascular Medicine, SWICFT Institute
James V Talano, MD, MM, FACC is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Physician Executives, American College of Physicians, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, and Society of Geriatric Cardiology
Disclosure: Nothing to disclose.

Carla Vaccaro, MD, Consulting Staff, Department of Family Practice, Merrimack Family Medicine
Carla Vaccaro, MD is a member of the following medical societies: Massachusetts Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Gary E Sander, MD, PhD, Professor, Department of Internal Medicine, Division of Cardiology, Tulane University Health Sciences Center
Gary E Sander, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Heart Association, American Society of Hypertension, Heart Failure Society of America, Louisiana State Medical Society, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Frank M Sheridan, MD, Cardiology, Providence Everett Medical Center
Frank M Sheridan, MD is a member of the following medical societies: American College of Cardiology, American Heart Association, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Patrice Delafontaine, MD, FACC, FAHA, FACP, FESC, Sidney W and Marilyn S Lassen Professor of Cardiovascular Medicine, Chief, Section of Cardiology, Director, Cardiovascular Center of Excellence, Tulane University; Professor of Physiology, Chair, Department of Medicine, Tulane University School of Medicine
Patrice Delafontaine, MD, FACC, FAHA, FACP, FESC is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American College of Cardiology, American College of Physicians, American Diabetes Association, American Federation for Clinical Research, American Federation for Medical Research, American Heart Association, American Medical Association, American Society for Clinical Investigation, Association of American Physicians, Association of Professors of Cardiology, Association of Professors of Medicine, Endocrine Society, European Society of Cardiology, Louisiana State Medical Society, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
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