Beta-Blockers for Cocaine-Associated Chest Pain

Guidelines and Expert Opinion

The American Heart Association (AHA) recommends the avoidance of beta-blockers acutely in the presence of cocaine to reduce the risk of exacerbating coronary spasm, and also in patients with a low output state or at increased risk for cardiogenic shock (age > 70 years, systolic blood pressure < 120 mm Hg, presenting heart rate > 110 bpm or increased length of time since onset of symptoms of ST-segment–elevation MI [STEMI]).^[20] This recommendation is mirrored in both the AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care and the ACC/AHA STEMI guidelines.^[5,20,21] However, according to a 2012 update for unstable angina/STEMI guidelines, "administration of combined alpha- and beta-blocking agents (eg, labetalol) may be reasonable for patients after cocaine use with hypertension (systolic blood pressure >150 mm Hg) or for those with sinus tachycardia (pulse >100 beats per minute) provided that the patient has received a vasodilator such as NTG [nitroglycerin] or a calcium channel blocker, within close temporal proximity (ie, within the previous hour)."^[5]

These recommendations have been established largely by case reports and animal studies in the absence of prospective clinical trials. Expert opinion suggests that the use of a beta-blocker in the presence of cocaine-associated chest pain or cocaine-associated ACS could be considered in some clinical situations.^[4,5,7,20]

For patients with compelling indications for beta-blockers, such as MI, left ventricular systolic dysfunction, ventricular arrhythmias, and coronary artery disease, the cardiovascular benefits of using beta-blockers may outweigh the risks of concomitant use with cocaine.^[4]

Given the risk of cocaine-associated vasoconstriction with selective beta-blockers and unopposed alpha-adrenergic effects of cocaine, nonselective options such as labetalol and carvedilol, which have demonstrated safety and potential benefit, should be considered and may be continued if chronic treatment with a beta-blocker is warranted.^[7,22,23] Beta-blockers that should not be used include esmolol, which may increase blood pressure,^[14] and propranolol, which may induce coronary artery vasospasm.^[23,24]

Conclusion

Chest pain is one of the most common presentations to the emergency department among cocaine users.

While there is a consensus that cocaine causes cardiotoxicity that is multifactorial in nature, the role of beta-blockers in mitigating its effects remains unclear. With no prospective, randomized controlled trials of cocaine-associated events available, therapeutic recommendations for beta-blockers are limited. Cocaine-associated chest pain may be treated in the same manner as ACS—that is, treatment with beta-blockers, specifically combined alpha- and beta-blocking agents—with the exception of cocaine-associated STEMI if the risk for MI outweighs the risk for coronary spasm. Furthermore, the decision to continue beta-blockade should be individualized on the basis of risk versus benefit.

Until further prospective studies are available to guide clinical judgement, beta-blocker use in the presence of cocaine should be reserved for acute treatment of life-threatening hypertension or tachycardia and given with a vasodilator such as nitroglycerin or a calcium channel blocker. Additionally, if a beta-blocker is used, one with both alpha- and beta-blocking activity should be chosen.

Chronic treatment for cardiovascular risk reduction in patients with a history of MI, left ventricular systolic dysfunction, or ventricular arrhythmias may be a consideration in cases where expected benefit exceeds risk.

The author wishes to acknowledge the assistance of Caitlin Huffman, PharmD, RPh; Jazmin Turner, PharmD, RPh; and Safiya Naidjate, PharmD, RPh, PGY1 residents at Northeastern University School of Pharmacy, in collaboration with Federally Qualified Health Centers and the Program of All-Inclusive Care for the Elderly, Boston, Massachusetts.

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