Arterial thrombosis and especially coronary thrombosis are known complications of cocaine abuse. We report three cases of severe life-threatening coronary arterial thrombosis manifesting as acute coronary syndromes. Thrombosis occurred predominantly in the proximal coronary tree with spontaneous distal embolization. The thrombotic occlusions were frequently not superimposed on flow-limiting atherosclerotic lesions. Treatment of these patients with thrombolytic, antithrombotic and anti-platelet therapy resulted in thrombus and symptom resolution. While stenting these vessels can be successfully executed and may be required in some cases of ST-elevation myocardial infarction, it may expose these patients to the risk of stent thrombosis, which is reported to be significantly higher than the risk of the general population.
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