ON November 25 the sporting world was jolted by news of the sudden death of football legend Diego Maradona of Argentina.

Maradona died at a relatively young age of 60 after a tumultuous life that was marked by highly publicised excesses and overindulgence in drugs and alcohol. The footballing demigod was reported to have suffered a heart attack at home, two weeks after being released from hospital following surgery for a bleed on his brain.

While it is unclear as to the proximate cause of the heart attack, there has been wide speculation about a possible causative role of cocaine given the footballing legend’s well-documented tortuous history of cocaine abuse over the years. His unfortunate and untimely death presents an opportunity to bring the cardiac effects of cocaine into public focus.

Cocaine is the second most used illicit drug and the most frequent cause of drug-related deaths. Cocaine use is associated with both acute and long-term complications that may involve any organ system in the body but the cardiovascular system is the most affected system – with heart attacks, strokes and vascular tears being some of the most fatal and debilitating acute events.

While sudden deaths from cocaine abuse attracts the most attention, cocaine misuse has a major effect in users — resulting in loss of productivity and undue morbidity due to cocaine-related cardiac and cerebrovascular effects. Even though these deleterious effects are well documented and well known to health care practitioners, many cocaine users have little or no idea of the risks associated with its use. It is important that the public is educated about the dangers and the considerable risks of cocaine use. In today’s column we hope to highlight some of the dangers of cocaine on the heart and the vascular system. 

Cardiovascular effects of cocaine

Cocaine acts as a powerful stimulant and is capable of causing marked and dangerous increases in blood pressure and one’s heart rate, which increases with the dose of cocaine use irrespective of how it is administered. The most common symptom in cocaine users is chest pain, and the most common cardiac disorders include impaired circulations, acute obstruction of heart vessels and exaggerated plaque development in heart vessels, which can occur with all routes of cocaine intake.

Other cardiac problems include myocarditis (inflammation of the heart muscles), cardiomyopathy (damage to the heart muscles), arrythmias (irregular heart rhythm) or a tear of the aorta (aortic dissection) which could be life threatening. 

Cocaine-related chest pain and heart attack

The most common heart-related complaint associated with cocaine abuse is chest pain, which can be seen in up to 60 per cent of individuals admitted to the hospital following cocaine misuse. 

A heart attack resulting from cocaine use involves several mechanisms. It is related to exaggerated increases in heart rate and blood pressure and simultaneous vasospasm of the heart vessels with reduced oxygen delivery to the heart muscles. In addition, cocaine activates blood platelets, promoting clot formation in the heart vessels.

Heart attacks following cocaine abuse can occur within minutes of cocaine ingestion or may occur as late as three to five days after cocaine use. The highest risk is in the first hour after cocaine use, with no relation to the dose or route of administration. A cocaine-induced heart attack often occurs in otherwise healthy patients with normal coronary arteries and the typical patients are usually young adults, with about half of these patients reporting previous chest pain complaints. Young patients presenting with chest pain and suspected heart attack should be questioned about cocaine use. 

Irregular heart rhythms

A wide range of heart rhythm abnormalities (arrhythmias) are known to occur with cocaine use. These abnormal heart rhythms are often transient and may resolve with time but sometimes fatal arrythmias may occur, leading to sudden death. 

Heart muscle inflammation and enlargement

Damage of heart muscles and enlargement of heart chambers can result from chronic cocaine abuse and is thought to be related to the toxic effect of cocaine on the heart — leading to inflammation, muscle damage and heart failure.

Inflammation of the heart muscle has been noted in 20 to 30 per cent of patients dying from cocaine misuse. Fortunately, abnormal heart function from cocaine misuse is reversible with abstinence and this fact should thus encourage recommendations for individuals to discontinue cocaine use even if abnormal heart function has already developed. Heart failure and heart enlargement in a young person should raise the possibility of cocaine misuse. 

Stroke

Cocaine use significantly increases the risk of stroke, which could result either from bleeding in the vessels in the brain or obstruction of blood flow and oxygen delivery to the brain. Cocaine causes the release of certain chemicals that cause intense spasm of the blood vessels in the brain and may also cause clot formation, leading to poor oxygen delivery to the brain.

The risk of bleeding in brain blood vessels is increased with continuous cocaine use because of weakened vessel walls that result from the repeated deficits in oxygen supply to the brain. Cocaine can also lead to the rupture of pre-existing blood vessel aneurysms, leading to a stroke. Long-term cocaine use can also lead to cognitive deficits. 

Infection of heart vessels

Cocaine use is a major risk factor for developing serious infection of heart vessels. It is presumed the increase in heart rate and blood pressure that result from cocaine use may lead to damage of the heart valves and may cause sustained injury to the vessels, increasing predisposition to bacterial invasion. Cocaine also increases immunosuppression in individuals and so increases the risk of infection. 

Aortic dissection (tear of the major blood vessel)

The use of cocaine, especially the crack cocaine variant, can lead to an acute tear (dissection) of the main blood vessel (aorta) — a condition known as aortic dissection. Dissection results from severe increase in systemic arterial pressure caused by cocaine and should be considered as a possible cause of chest pain in cocaine users. The aorta is the main conduit moving blood from the heart to other organs and so is critical for survival. Acute dissection, or tear of the aorta, in the proximal part of the vessel is particularly dangerous and can quickly lead to death without immediate surgical intervention. 

Final thoughts

The recognition of cocaine as a causative agent for heart-related problems is crucial for optimal treatment. Cocaine use should always be considered in previously healthy young persons presenting with chest pain or heart attack. Because many cocaine users may be unaware of the many risks associated with its use, it is important that appropriate attention be paid to public education about the dangers associated with cocaine use.

Education about the dangers and the significant risks of cocaine use should also be directed at health care professionals. People who engage in cocaine misuse or who have developed a dependence on it should be encouraged to stop and when possible ,should be referred for rehabilitation if such facilities are available. 

Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists at Heart Institute of the Caribbean (HIC) and HIC Heart Hospital

Dr Madu is a main TED Speaker whose TED talk has been translated into 19 languages, seen, and shared by over 500,000 viewers. He has received the Distinguished Cardiologist Award, the highest award from the American College of Cardiology and has been named among the 100 most influential people in health care and among the 30 most influential in Public Health.

Dr Madu is also a recipient of the Global Health Champion Award from the University of Pennsylvania.

Correspondence to info@caribbeanheart.com or call 876-906-2107