Should we consider cocaine induced chest pain as ischemic and be treating with ASA and NTG? Example: 20 year old male patient midsternal chest tightness. Admits to using cocaine and the symptoms occurring after that. I guess my question is, is the cocaine causing ischemia which causes the chest pain?

Cocaine use can absolutely be associated with ischemic chest pain. Patients presenting with chest pain after cocaine may be considered for treatment per the Cardiac Ischemia Medical Directive.

Cocaine causes myocardial ischemia in a multifactorial fashion that includes: (1) increasing myocardial oxygen demand by increasing heart rate, blood pressure, and contractility; (2) decreasing oxygen supply via vasoconstriction; (3) inducing a prothrombotic state by stimulating platelet activation and (4) accelerating atherosclerosis.

Cardiac Ischemia,Cardiac/Circulation

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McCord J, et al; American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Management of cocaine-associated chest pain and myocardial infarction: a scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Circulation. 2008 Apr 8;117(14):1897-907. doi: 10.1161/CIRCULATIONAHA.107.188950. Epub 2008 Mar 17. PMID: 18347214.