Evaluation and management of the patient who has cocaine-associated chest pain

Patients who have cocaine-associated chest pain are being seen more commonly in emergency departments throughout the United States, with approximately 6% of these patients sustaining an acute myocardial infarction. The authors describe the rationale for recommending aspirin, benzodiazepines, and nitroglycerin as first-line treatments and calcium-channel blockade or phentolamine as possible second-line therapies. They present the rationale for withholding beta-adrenergic antagonists in patients who have cocaine-associated chest pain and summarize the controversies surrounding the use of fibrinolytic agents. Patient disposition, the approach to risk stratification, and inpatient and subsequent outpatient evaluation are discussed.