A fictional 38-year-old develops abrupt severe chest pain after cocaine use, with marked hypertension and pain radiating to the back.
Listen for the assumption.
This is vasospasm, so I will treat it exactly like uncomplicated ACS.
What diagnoses must stay alive before antithrombotic or reperfusion decisions?
ACS is possible, but the abrupt back-radiating pain and hypertension require assessment for acute aortic syndrome and senior cardiology/toxicology involvement.
Choose an answer below and reveal the reasoning to see consultant feedback at every checkpoint. The full consultant-led synthesis follows after all three decisions.
Go to the first decision ↓The picture develops.
- Abrupt severe chest pain radiating to the back
- Marked hypertension and tachycardia
- Recent stimulant use
Commit before you reveal.
After you select an option, reveal the model reasoning and the consultant’s feedback.
Hear the senior team refine the plan.
The registrar tests the plan, the consultant synthesises the key principle, and the SHO confirms the safer next steps.
Ask non-judgementally about timing and co-exposures, but base emergency testing on physiology and the pain phenotype.
Cocaine is an important modifier, not a shortcut. Treatment choices must be current-protocol and specialist-led.
I will hand over ECG/troponin trajectory, pain phenotype, aortic concern, imaging plan and specialist advice.
What must remain explicit.
- Use current local chest-pain, aortic-syndrome and toxicology pathways.
- Escalate shock, neurological deficit, pulse deficit or persistent severe pain immediately.
- This is not a medication algorithm.
Where reasoning fails.
- Anchoring on vasospasm
- Judgemental substance-use history
- Prematurely committing to an antithrombotic pathway
High-risk chest pain after stimulant use: pain [phenotype/trajectory], observations [trend], ECG/troponin [status], aortic concern [why], imaging/specialist plan [details].
Which question in the pain history most changes your differential?