Objective: Myocardial ischemia, secondary to coronary vasospasm, plaque rupture, or stress demand related to catecholamine release, has been reported following acute cocaine use. We describe a case of electrocardiogram findings consistent with Wellens syndrome 36 hours after reported cocaine use.
Case report: A 22 year old man with a history of hepatitis C and polysubstance abuse presented to the Emergency Department after intravenous heroin use and naloxone administration complaining of body aches, chills, chest pain, and shortness of breath. He admitted to snorting and injecting crack cocaine 24 hours prior. He was afebrile with a blood pressure of 111/74 mm Hg, heart rate of 88 beats per minute, respiratory rate of 17 breaths per minute, and SpO 2 of 100% on 3 liters per minute of oxygen. Physical examination revealed pinpoint pupils, slurred speech, and track marks. His cardiopulmonary examination was normal. The electrocardiogram showed normal sinus rhythm with ST depression in leads V3, V4, and V5, and his troponin measured 0.039 ng/mL (normal: 0.03 ng/mL). His chest x-ray was negative, and the urine drug immunoassay was positive for opiates and cocaine metabolites. He had no known family history of coronary artery disease. Within 12 hours, his symptoms resolved, troponin peaked at 0.159 ng/mL, and ECG showed biphasic T-waves in leads V2 and V3. Echocardiography revealed mild hypokinesis with an ejection fraction of 45 . 50% and no regional wall motion abnormalities. Cardiology did not recommend angiography due to a low suspicion for occlusive atherosclerotic disease.
Conclusion: Wellens syndrome is characterized by biphasic or inverted T-waves in the anterior leads of the electrocardiogram and is associated with high-grade occlusion of the proximal left anterior descending coronary artery. Pseudo-Wellens, defined by classic electrocardiogram findings in the absence of occlusive disease, has been described in the setting of cocaine use and attributed to focal coronary artery vasospasm. Healthcare providers should be cognizant of electrocardiogram findings indicative of Wellens syndrome in patients presenting with chest pain after cocaine use.