Printer Friendly

Acute myocardial infarction following the use of intranasal anesthetic cocaine.

Abstract: The use of cocaine has become largely obsolete in modern medical practice; however, it is still used by otolaryngologists for topical anesthesia in head and neck surgeries. We present the case of a 68-year-old woman who developed a myocardial infarction after the use of topical cocaine during nasal sinus surgery, and review the literature regarding the use of cocaine as a topical anesthetic in otolaryngologic practice. Awareness is raised of a possible complication of myocardial infarction following topical cocaine anesthetic use.

Key Words: acute myocardial infarction, cocaine, intranasal, anesthesia

**********

The initial medical anesthetic use of pure cocaine was in the 1880s as a topical agent in eye, nose, and throat surgeries because of its ability to provide anesthesia as well as to constrict blood vessels and limit bleeding. Although the medical use of cocaine has for the most part become obsolete, it is still used at times by otolaryngologists for topical anesthesia in head and neck surgeries. (1) We present the case of a 68-year-old woman who developed a myocardial infarction after the use of topical cocaine during nasal sinus surgery, and review the literature regarding the use of cocaine as a topical anesthetic in otolaryngologic practice. Awareness is raised of a possible complication of myocardial infarction following use of topical cocaine anesthesia.

Case Report

A 68-year-old female with a past medical history of mitral valve prolapse presented to the hospital for elective bilateral sphenoidectomy and septoplasty for a history of chronic postnasal drip. In the patient's preoperative workup, an exercise echocardiogram demonstrated mitral valve prolapse with mitral insufficiency and significant S-T segment deviations which persisted for approximately seven minutes. Subsequent diagnostic cardiac catheterization showed normal right heart filling pressures with a normal left ventricular diastolic pressure of 6 mm Hg, cardiac index of 2.391/min-[m.sup.2], and an ejection fraction of 60 to 65%. Angiography demonstrated right-dominant circulation with no stenosis.

The patient was prepared for the intranasal surgical procedure. After she was sedated and intubated, 4% topical cocaine hydrochloride was applied intranasally for local vasoconstriction and anesthesia. Soon after, the patient became significantly hypotensive (70/40) and bradycardic with a heart rate in the 30s. The procedure was immediately halted. ECG revealed sinus bradycardia with 1 mm S-T segment depressions in leads I, AVL, V5, and V6. A subsequent bedside transthoracic echocardiogram (TTE) showed severe segmental left ventricular systolic dysfunction with akinesis of the middle and distal segments of the left ventricle and hypokinesis of the mid and distal inferior walls.

The patient was admitted to the intensive care unit (ICU) and treated for acute myocardial infarction with cardiogenic shock. Her cardiac index on Swan-Ganz catheterization was 1.8. The peak troponin level was 15.4 ng/mL. She required pressor support with norepinephrine and inotropic support with dobutamine. Within 24 hours, her condition improved and the norepinephrine and dobutamine drips were tapered off. Her clinical status progressively improved and she was discharged home with appropriate medical management and outpatient follow-up.

Discussion

Although the use of cocaine as a medicinal agent dates back more than 1,000 years, pure cocaine was first used as a local anesthetic during the 1880s in eye, nose, and throat surgeries due to its potency as an anesthetic agent as well as its ability to limit blood loss via its vasoconstrictive properties. Despite the development of anesthetic agents with similar properties and more favorable safety profiles, however, cocaine solutions are still widely used as topical anesthetic agents primarily in otolaryngological procedures due to the unique vasoconstrictive potency of cocaine in limiting epistaxis during intranasal procedures. (1,2)

The adverse cardiovascular effects of chronic cocaine abuse have been well documented in the literature and include, among others, myocardial infarction, myocarditis, coronary artery aneurysms, aortic dissection, left ventricular hypertrophy, and exacerbation of underlying hypertension and coronary atherosclerosis. (1-3) Although there have been several reported cases of cardiovascular morbidity with the illicit use of cocaine, (4-7) it must be realized that the use of anesthetic cocaine may also lead to cardiac complications. Such risk is often neglected, most likely as a result of the lack of sufficient research regarding the likelihood of negative cardiac outcomes, particularly in patients already predisposed to myocardial injury secondary to coronary atherosclerosis or left ventricular hypertrophy, for example.

Applied locally, cocaine exhibits significant anesthetic potency primarily as a consequence of its inhibition of membrane sodium channel permeability during electrical depolarization. When administered systemically, however, cocaine acts via alterations in norepinephrine and dopamine-mediated synaptic transmission by decreasing presynaptic reuptake of these two neurotransmitters, thereby producing an enhanced sympathetic effect. Although the precise mechanism regarding the correlation between intranasal anesthetic cocaine and acute cardiac events remains unclear, there is speculation that the adverse effect is the result of systemic concentrations sufficient to induce an enhanced sympathetic response, particularly given the rapid absorption rate of topical intranasal cocaine. (2)

Although evidence of cardiovascular toxicity is included in the pharmacologic literature regarding cocaine-derived anesthetics, it is our hope that with increased awareness regarding the occurrence of severe adverse cardiac events following the use of cocaine anesthetics, patients scheduled to undergo procedures involving this type of anesthesia will be screened more carefully to avoid negative outcomes. Whether more rigorous screening will prevent negative outcomes is unclear: nevertheless, in the case presented above, the patient's preoperative workup demonstrated significant exercise-induced ischemia in addition to her mitral valve abnormalities. Although the subsequent diagnostic cardiac catheterization showed no significant stenosis, topical cocaine was most likely not the optimal choice for this particular patient given the presence of ST-T segment changes on exercise echocardiography. Further complicating attempts at risk stratification is the fact that cocaine in both the recreational and anesthetic form has been shown to cause myocardial ischemia even in patients with angiographically normal coronary arteries. (2) Our patient likely experienced coronary vasospasm from systemic absorption of the intranasal cocaine.

Although cocaine has certain properties which render it very useful in otolaryngological procedures, patients with predisposing cardiovascular risk factors such as diabetes mellitus, obesity, dyslipidemia, and smoking history should undergo extensive cardiac screening before undergoing procedures in which cocaine will be used. Alternatively, other anesthetic agents with similar properties might be considered.

There are to our knowledge, only seven other reported cases of myocardial infarction following the intraoperative use of cocaine as an anesthetic agent in otolaryngological procedures (Table). (6-11) Nevertheless, we hope to increase awareness of the possible significant complications of using cocaine as an anesthetic agent. Despite the relatively small number of reported cases of acute cardiovascular toxicity following the use of cocaine anesthetics, the magnitude of the possible negative outcomes warrants a certain degree of caution before proceeding. Although cocaine remains a safe and useful anesthetic agent in otolaryngological procedures, the awareness of possible myocardial toxicity intraoperatively is a necessity to ensure prompt evaluation and management.

Conclusion

The wide use of topical cocaine as a local anesthetic for otolaryngologic procedures necessitates the realization of the adverse effects of this agent. Our patient suffered an acute nontransmural myocardial infarction following clinical use of cocaine as topical anesthesia for nasal surgery, one of only eight such cases, to our knowledge, which has been documented in the literature. Although evidence documenting the cardiovascular toxicity of cocaine is noted in the pharmacologic literature, clinical cardiac injury has been emphasized to date only with the recreational use of cocaine. The risk of myocardial infarction with the use of intranasal cocaine must be realized, especially in patients with either a history of coronary disease or with risk factors for coronary disease.

References

1. Pozner CN, Levine M. Zane R. The cardiovascular effects of cocaine. J Emerg Med 2005;29:173-178.

2. Johns ME, Henderson RL. Cocaine use by the otolaryngologists: a survey. Trans Sect Otolaryngol Am Acad Ophthalmol Otolaryngol 1977;84:969-973.

3. Satran A, Bart BA, Henry CR, et al. Increased prevalence of coronary artery aneurysms among cocaine users. Circulation 2005;111:2424-2429.

4. Velasquez EM, Anand RC. Newman WP III, et al. Cardiovascular complications associated with cocaine use. J La State Med Soc 2004:156:302-310.

5. Lange RA, Hillis LD. Cardiovascular complications of cocaine use. N Engl J Med 2001;345:351-358.

6. Laffey JG, Neligan P, Ormonde G. Prolonged perioperative myocardial ischemia in a young male: due to topical intranasal cocaine? J Clin Anesth 1999;11:419-424.

7. Minor RL Jr, Scott BD. Brown DD, et al. Cocaine-induced myocardial infarction in patients with normal coronary arteries. Ann Intern Med 1991;115:797-806.

8. Chiu YC, Brecht K. DasGupta DS, et al. Myocardial infarction with topical cocaine anesthesia for nasal surgery. Arch Otolaryngol Head Neck Surg 1986;112:988-990.

9. Ashchi M, Wiedemann HP, James KB. Cardiac complication from use of cocaine and phenylephrine in nasal septoplasty. Arch Otolaryngol Head Neck Surg 1995;121:681-684.

10. Littlewood SC, Tabb HD. Myocardial ischemia with epinephrine and cocaine during septoplasty. J La State Med Soc 1987;139:15-18.

11. Young D. Glauber JJ. Electrocardiographic changes resulting from acute cocaine intoxication. Am Heart J 1946;34:272-279.
Be curious, not judgmental.
--Walt Whitman


John N. Makaryus, MD, Amgad N. Makaryus, MD, and Michelle Johnson, MD

From the Department of Medicine, Division of Cardiology, North Shore University Hospital, Manhasset, NY

Reprint requests to Michelle Johnson, MD, Division of Cardiology, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030. Email: mjohnson@nshs.edu

Accepted April 4, 2006.

RELATED ARTICLE: Key Points

* The initial use of pure cocaine in anesthesia was in the 1880s as a topical agent in eye, nose, and throat surgeries because of its ability to provide anesthesia as well as to constrict blood vessels and limit bleeding.

* Although the medical use of cocaine has now for the most part become obsolete, it is still widely used by otolaryngologists for topical anesthesia in head and neck surgeries.

* The wide use of topical cocaine as a local anesthetic for otolaryngologic procedures necessitates the realization of the adverse effects of this agent.

* Although evidence documenting the cardiovascular toxicity of cocaine is noted in the pharmacologic literature, clinical cardiac injury has been emphasized to date only with the recreational use of cocaine. The risk of myocardial infarction with the use of intranasal cocaine must be realized, especially in patients with either a history of coronary disease or with risk factors for coronary disease.
Table. Reported cardiac complications from topical cocaine use

 Age Cocaine Cardiac
 (years)/ preparation Surgical sequelae and
Report sex (%/4 mL) procedure outcome

Makaryus 68/F 4 Elective Acute non-Q
 et al bilateral wave
 (2006, sphenoidectomy myocardial
 current and septoplasty infarction
 report) and
 cardiogenic
 shock
Ashchi et al 23/F 4 Elective nasal Non-Q wave
 (1995) (9) septoplasty myocardial
 infarction
Minor et al 60/F 5 Biopsy of Ventricular
 (1991) (7) supraglottic tachycardia,
 mass hypotension,
 anterolateral
 myocardial
 infarction
Littlewood 44/M 1 Nasal septoplasty Myocardial
 and Tabb ischemia
 (1987) (10)
Chiu et al 28/F 25 Closed reduction Myocardial
 (1986) (8) of nasal infarction
 fracture
Young and 20/M 20 Nasal submucous Cardiopulmonary
 Glauber resection arrest and
 (1946) (11) death

M. male: F. female.
COPYRIGHT 2006 Southern Medical Association
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2006, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

Article Details
Printer friendly Cite/link Email Feedback
Title Annotation:Case Report; medical research; includes related article "Key Points" and statistical table
Author:Johnson, Michelle
Publication:Southern Medical Journal
Geographic Code:1U600
Date:Jul 1, 2006
Words:1836
Previous Article:Concomitant intracranial aneurysm and carotid artery stenosis: a therapeutic dilemma.
Next Article:A case of laryngotracheal stenosis masquerading as asthma.
Topics:


Related Articles
Cocaine use boosts heart-attack risk.
Cardioembolic stroke: an update. (Review Article).
Unappreciable myocardial bridge causing anterior myocardial infarction and postinfarction angina. (Case Report).
Acute renal infarction as a cause of low-back pain. (Case Report).
Evaluation of lactate and C-reactive protein in the assessment of acute myocardial infarction.
Fatal cardiac rupture during stress exercise testing: case series and review of the literature.
Tenecteplase and return of spontaneous circulation after refractory cardiopulmonary arrest.
Refractory hypoxemia in right ventricular infarction: a case report.
Non-ST segment elevation acute coronary syndromes: a comprehensive review.
A case-control analysis of exposure to traffic and acute myocardial infarction.

Terms of use | Copyright © 2018 Farlex, Inc. | Feedback | For webmasters