Cocaine-induced myocardial infarction: not your average acute coronary syndrome.

A 31-year-old woman presented to accident and emergency at 03.20 hrs complaining of central chest pain since the preceding evening. She denied any significant medical history or family history and initially denied taking any medication or drugs of abuse. On examination her pulse was 110 beats per minute and her blood pressure 126/82 mmHg but there were no other abnormal physical findings. Her initial electrocardiogram showed multiple ventricular ectopics with periods of idioventricular rhythm but no acute ST segment elevation that met thrombolysis criteria (Figure 1). She was initially treated with aspirin, low molecular weight heparin and intravenous nitrates. Although her symptoms of pain resolved overnight, the electrocardiogram evolved Q waves suggesting a significant anterior myocardial infarction (Figure 2). This was confirmed by a raised cardiac troponin T level at 12 hours. It was not until some 15 hours after admission, and only after direct questioning, that she admitted to being a regular cocai...