In cocaine-induced myocardial ischemia, which therapy is preferred?

In cocaine-induced myocardial ischemia, which therapy is preferred?

• A. Beta-blockers
• B. Calcium channel blockers
• C. Thrombolytics
• D. Anticoagulation with heparin only

Answer: (B)

Cocaine-induced myocardial ischemia mainly comes from marked coronary vasospasm due to a surge in sympathetic activity, so the therapy that best addresses the underlying problem is one that relaxes the coronary smooth muscle and prevents vasoconstriction. Calcium channel blockers do just that: they block calcium entry into vascular smooth muscle, causing dilation of the coronary arteries and relief of vasospasm, which improves blood flow and reduces myocardial oxygen demand. This direct vasodilatory effect makes them the preferred treatment in this scenario. Beta-blockers are avoided because, in the setting of cocaine use, they can blunt protective beta-mediated effects and leave alpha-adrenergic vasoconstriction unopposed, potentially worsening the ischemia. Thrombolytics are not routinely indicated unless there is a clear thrombotic STEMI, since the primary issue here is vasospasm rather than a thrombus. Anticoagulation with heparin alone does not address the vasospasm and therefore is not the preferred standalone therapy.

Cocaine-induced myocardial ischemia mainly comes from marked coronary vasospasm due to a surge in sympathetic activity, so the therapy that best addresses the underlying problem is one that relaxes the coronary smooth muscle and prevents vasoconstriction. Calcium channel blockers do just that: they block calcium entry into vascular smooth muscle, causing dilation of the coronary arteries and relief of vasospasm, which improves blood flow and reduces myocardial oxygen demand. This direct vasodilatory effect makes them the preferred treatment in this scenario.

Beta-blockers are avoided because, in the setting of cocaine use, they can blunt protective beta-mediated effects and leave alpha-adrenergic vasoconstriction unopposed, potentially worsening the ischemia. Thrombolytics are not routinely indicated unless there is a clear thrombotic STEMI, since the primary issue here is vasospasm rather than a thrombus. Anticoagulation with heparin alone does not address the vasospasm and therefore is not the preferred standalone therapy.