Authors' reply (acute myocardial infarction and cocaine toxicity: One step closer).

Sir,

The article of Senthilkumaran et al.[1] in response to our article[2] pertinently raises the rising concern of substance abuse induced coronary artery disease in Indian subcontinent. Some of the points raised by them however need further clarifications. First, the controversy of thrombolysis in our patient of cocaine induced myocardial infarction (CAMI). As per the current guidelines thrombolysis is not contraindicated in CAMI, though primary percutaneous intervention (PCI) is definitely the preferred option.[3] This strategy is even more relevant in a country like India, where majority of our health care facilities are non-PCI capable. We should not deprive these patients the benefit of timely thrombolysis when there are no other contraindications and primary PCI is not available. However, caution should be applied in thrombolytic therapy as cocaine users may have altered consciousness = induced fall and trauma, with some of the injuries not obvious on initial evaluation. Regarding our patient, we could not proceed with primary PCI due to financial constraints of the patient.

Secondly, the role of calcium channel blockers in the treatment of patients with cocaine-associated acute coronary syndrome remains uncertain. Calcium channel blockers should not be used as a first-line treatment, but may be considered for patients who do not respond to benzodiazepines and nitroglycerin.[3]

Regarding cardiac biomarkers, it was rightly pointed out that serum creatinine kinase level is not a reliable indicator of myocardial injury in cocaine users. This is the reason we went for additional measurement of troponine T in our patient.

Finally, through this letter, we seize the opportunity to share the present status of the index patient who is on our close follow-up for almost 2.5 years now. Apart from the cardiac medications, he was made to attend a strict de-addiction program. Currently, he is asymptomatic and his left ventricular ejection fraction went up to more than 50%.