A 25-year-old man presents to the emergency department with acute chest pain 30 minutes after smoking crack cocaine. His ECG shows sinus tachycardia and no evidence of acute ischemia. His chest x-ray is normal. His initial troponin is normal. Which of the following treatments would you use first in the management of his chest pain?
Benzodiazepines are the first-line therapy in patients with cocaine-associated chest pain. Two randomized clinical trials have demonstrated beneficial effects in patients with cocaine-associated ACS-type chest pain. Numerous animal studies confirm increased survival in cocaine intoxication with benzodiazepine administration. This patient demonstrates no evidence of ischemia or infarction to suggest a role for heparin. Controversy exists in the role of beta-adrenergic antagonists in cocaine-induced chest pain. Current consensus guidelines do not support its use in this setting. Morphine may improve the patient’s pain and could be considered adjunctive therapy but does not have the clinical benefit of a benzodiazepine. Nitroglycerin is appropriate early therapy for cocaine-associated hypertension, but there is no evidence to support its role over diazepam in this patient.