Adverse Events Are Not Increased with Beta-Blockers in Cocaine Chest Pain

Although beta-blockers improve outcomes in patients with myocardial infarction, cardiology guidelines recommend against using beta-blockers in cocaine-associated chest pain because of concerns about the unopposed alpha-adrenergic stimulation shown in case reports and animal studies. To determine whether beta-blockers are safe to administer to patients with chest pain and recent cocaine use, researchers reviewed the National Death Index and patient records of 331 patients with chest pain and cocaine-positive urine test results admitted to San Francisco General Hospital between 2001 and 2005.

• One hundred fifty-one patients received a beta-blocker in the emergency department (ED). Of these, 85% received metoprolol as their first dose.

• During the hospitalization, systolic blood pressure decreased more in patients who received a beta-blocker in the ED. No differences in electrocardiograph results, troponin levels, intubation rates, vasopressor use, malignant ventricular arrhythmia rates, or death were found.

• There were 45 deaths (14% of the total sample) over a median follow-up of 972 days. In adjusted analyses, discharge on a beta-blocker regimen was associated with a lower risk of cardiovascular-specific death but not associated with all-cause mortality.

Comments:

Although this retrospective observational study does not definitively settle the debate regarding the safety of beta-blockers for patients with cocaine-related chest pain, it does credibly challenge guidelines that recommend against the use of beta-blockers for such patients at risk for myocardial infarction. Resolving this controversy will require further study, including a randomized controlled trial.

Alexander Y. Walley, MD, MSc

Reference:

Rangel C, Shu RG, Lazar LD, et al. Beta-blockers for chest pain associated with recent cocaine use. Arch Intern Med. 2010;170(10):874–9.