Chest Pain, Chest Pain Everywhere

Today’s intern conference was about 2 entirely different etiologies of chest pain.

Case #1

18 y.o. high school football player complains of chest pain after workout. Clinical course precipitously deteriorated with hypotension and tachycardia. Labs show elevated CK, renal failure, elevated K and P. Patient then decompensated and died. Post-mortem studies sh0w that patient has sickle cell trait, which is risk factor for sudden death. African-Americans with sickle cell trait have a 30x greater risk of death than those without sickle cell trait.

Sickle Cell Trait and Sudden Death – Bringing it Home – J Natl Med Assoc. 2007 March; 99(3): 300-305

Case #2

45 y.o. with DM, HTN, crack-cocaine abuse presents with chest pain and markedly elevated BP. U-tox positive for cocaine and had EtOH on board. Chest pain related to cocaine is found to be an MI 0.7%-6% of the time. The remainder of chest pain is attributable to coronary vasospasm.  Cocaine users are at higher risk for plaque rupture and ACS, so remember to assess them as you would other chest pain patients.

Management of Cocaine-Associated Chest Pain and Myocardial Infarction – Circulation 2008; 117: 1897-1907
Co-authored by our own George Philippedes!

Would you use B-blockers in a cocaine user? Guidelines say no, but that isn’t unanimous. The retrospective cohort below shows that B-blocker use in patients with cocaine-related chest pain did not have worse outcomes than those without B-blockers.

Beta-blockers for chest pain associated with recent cocaine use. – Arch Intern Med. 2010 May 24;170(10):874-9.