Clinical Images

Cocaine-Induced Microvascular Dysfunction and its Reversal by Administration of Intracoronary Calcium-Channel Blocker

Bhalaghuru Chokkalingam Mani, MD;  David L. Fischman, MD;  Michael P. Savage, MD

Bhalaghuru Chokkalingam Mani, MD;  David L. Fischman, MD;  Michael P. Savage, MD

Abstract: A 47-year-old male smoker with recent cocaine use presented with 6 hours of chest pain unrelieved by sublingual and intravenous nitroglycerin. To our knowledge, this is the first reported case demonstrating the efficacy of an intracoronary calcium-channel blocker to ameliorate cocaine-induced microvascular spasm.

J INVASIVE CARDIOL 2016;28(10):E120-E121

Key words: microvascular spasm, calcium-channel blocker


Case Presentation

A 47-year-old male smoker with recent cocaine use presented with 6 hours of chest pain unrelieved by sublingual and intravenous nitroglycerin. An electrocardiogram revealed anterior ST-segment elevations. Emergent coronary angiography revealed no obstructive coronary atherosclerotic disease, thrombus, or epicardial spasm. However, there was Thrombolysis in Myocardial Infarction (TIMI) grade 2 flow and an increase in TIMI frame counts of both left anterior descending and right coronary arteries (Videos 1 and 2). Administration of intracoronary nicardipine (200 µg), resulted in a significant improvement in coronary flow and TIMI frame counts (Figures 1A and 1B; Videos 3 and 4).

Cocaine has various detrimental cardiac effects including increased myocardial oxygen demand, coronary vasospasm, thrombosis, and microvascular dysfunction.1 In the absence of overt coronary atherosclerotic disease or spasm, slow coronary flow on angiography with increased TIMI frame counts serves as a marker of microvascular dysfunction.2 Our case illustrates the severe impairment of coronary flow due to cocaine even in the absence of significant epicardial disease and its rapid reversal by administration of intracoronary calcium-channel blockers. Intracoronary nicardipine is a potent dilator of the coronary microvasculature and has been commonly used to treat microvascular spasm associated with no-reflow during percutaneous coronary intervention.3,4 To our knowledge, this is the first reported case demonstrating the efficacy of an intracoronary calcium-channel blocker to ameliorate cocaine-induced microvascular spasm.

References

1.    Schwartz BG, Rezkalla S, Kloner RA. Cardiovascular effects of cocaine. Circulation. 2010;122:2558-2569. 

2.    Kelly RF, Sompalli V, Sattar P, Khankari K. Increased TIMI frame counts in cocaine users: a case for increased microvascular resistance in the absence of epicardial coronary disease or spasm. Clin Cardiol. 2003;26:319-322.

3.    Fischell TA, Maheshwari A. Current applications for nicardipine in invasive and interventional cardiology. J Invasive Cardiol. 2004;16:428-432.

4.    Huang RI, Patel P, Walinsky P, et al. Efficacy of intracoronary nicardipine in the treatment of no-reflow during percutaneous coronary intervention. Catheter Cardiovasc Interv. 2006;68:671-676.


From the Jefferson Angioplasty Center, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

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.

Manuscript submitted May 16, 2016 and accepted May 31, 2016.

Address for correspondence: Michael P. Savage, MD, Ralph J. Roberts Professor of Cardiology, Director, Cardiac Catheterization Laboratory, Thomas Jefferson University Hospital. Gibbon Bldg., Ste 6210, 111 S. 11th Street, Philadelphia, PA 19107. Email: michael.savage@jefferson.edu

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