The American College of Cardiology (ACC) and American Heart Association (AHA) guidelines recommend against the use of beta-blockers in patients with ST-elevation myocardial infarction (STEMI) precipitated by cocaine use due to increased risk of coronary spasm exacerbation. Death from cocaine-induced myocardial infarction is stated to be exceedingly low. Propranolol is also contraindicated in cocaine overdose and cocaine-induced acute coronary syndrome (ACS). It is further recommended that beta-blockers should be avoided in the treatment of cocaine toxicity in acute care settings. Use of esmolol, a short-acting selective beta-1 agonist, was associated with a significant increase in blood pressure in up to 25% of patients. Therefore, these findings do not support the use of selective beta-blockers. [1]
The 2012 American College of Cardiology Foundation and the American Heart Association (ACCF/AHA) guidelines on the management of unstable angina/non-ST-elevation myocardial infarction (non-STEMI) stated that the use of labetalol (a combined alpha and beta-blocker, unclear dosing) after cocaine exposure may be reasonable for patients who have systolic blood pressure greater than 150 mmHg or sinus tachycardia with a pulse greater than 100 beats per minutes, given that the patients have received a vasodilator (e.g., nitroglycerine, or calcium channel blocker) within close temporal proximity (e.g. within the previous hour) (Class IIb, level of evidence C). The guidelines recommend combination alpha and beta-blockade in addition to a vasodilator given that the use of beta-blockers in close proximity (i.e., within 4 to 6 hours) of cocaine exposure may cause some harm (e.g., myocardial ischemia). There is no mention regarding the use of selective beta-blockers. [2]
The 2014 American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of non-ST-elevation acute coronary syndrome (ACS) and the 2015 European Society of Cardiology (ESC) guidelines for the management of ACS without persistent STEMI state that beta-blockers should not be administered in patients with symptoms possibly related to coronary vasospasm or history of cocaine use who demonstrate signs of acute intoxication due to the risk of potentiating coronary spasm. The use of beta-blockers in recent cocaine exposure may precipitate harm due to the proposed risk of unopposed alpha-adrenergic stimulation and worsening coronary vasospasm. Cocaine actively affects both alpha and beta receptors; thus, administering a beta-blocker may leave alpha-mediated vasoconstriction unopposed causing a decrease in myocardial blood flow and coronary vasoconstriction. [3], [4]
A 2020 systematic review investigated the use of beta-blockers for treating heart failure patients with concurrent cocaine use. The review included studies of patients admitted for heart failure exacerbation who were actively using cocaine and received either selective or non-selective beta-blockers. Most of the included studies were retrospective in design. The review found that beta-blocker treatment was associated with either beneficial or non-inferior outcomes relative to readmission rates, myocardial infarction occurrence, and other cardiovascular outcomes, compared to controls. No additional adverse events attributable to beta-blocker use were observed among cocaine-using patients. However, the majority of patients across the included studies received carvedilol or labetalol, whereas only approximately 10% received more cardioselective beta-blockers. This limits conclusions regarding the relative safety and efficacy of selective versus non-selective beta-blockers in cocaine-using heart failure patients. [5]
A 2019 meta-analysis investigated in-hospital and long-term outcomes associated with beta-blocker treatment in recent or active cocaine users presenting with cocaine-associated chest pain. To be included, patients must have received beta-blockers either during hospitalization or in the emergency department setting. Across eight included studies involving 2,048 patients, the majority of beta-blocker use involved selective agents like metoprolol, propranolol, or atenolol. With a mean follow-up of 2.6 years, no significant differences were found in all-cause mortality (risk ratio [RR] 0.79; 95% confidence interval [CI] 0.44-1.41, I2= 26.6%) or myocardial infarction (RR 0.96; 95% CI 0.40-2.33, I2=0.0%) between patients receiving beta-blockers compared to non-receivers. However, the analysis did not specifically evaluate outcomes according to selective versus non-selective beta-blocker therapy, limiting conclusions regarding their relative safety and efficacy in the context of recent cocaine use. [6]
A 2019 meta-analysis examined the use of beta-blockers for acute cocaine-related chest pain. A total of 5 studies were included (N= 1,447) that assessed in-hospital rates of all-cause mortality and myocardial infarction. No significant differences were found between patients treated with beta-blockers versus those without in terms of myocardial infarction (RR 1.08; 95% CI 0.61 to 1.91) or all-cause mortality (RR 0.75; 95% CI 0.46 to 1.24). Metoprolol, a commonly used selective beta-blocker, appeared to be well tolerated across the included studies. Based on these findings, the authors concluded beta-blockers were not associated with adverse clinical outcomes in patients presenting with acute chest pain related to cocaine use, although the studies were largely retrospective in design. [7]
A 2018 systematic review and meta-analysis compared outcomes of beta-blockers versus no beta-blockers for adult patients with cocaine-associated chest pain. The ACC/AHA and ESC guidelines for the management of ACS in patients presenting without persistent STEMI, beta-blockers should not be administered to patients with non-STEMI precipitated by cocaine use because of the risk of potentiating coronary spasm. However, the authors disclaim that these recommendations may have been derived mostly from animal studies and trials with small sample sizes. Given the ongoing debate and conflicting data, the investigators performed a meta-analysis to assess the safety of beta-blocker therapy in patients with cocaine-associated chest pain; non-fatal myocardial infarction and all-cause mortality were among the outcomes of interest. Five studies with a total of 1,794 subjects were included. Overall, there was no significant difference in myocardial infarction between cocaine-associated chest pain patients on beta-blockers and those not on beta-blockers (odds ratio [OR] 1.36, 95% CI 0.68 to 2.75). Similarly, there was no statistically significant difference in all-cause mortality between patients taking a beta-blocker and those who did not (OR 0.68; 95% CI 0.26 to 1.79). Based on these findings, the authors concluded that beta-blocker use did not appear to be associated with an increased risk of MI or all-cause mortality in patients presenting with acute chest pain and underlying cocaine use. [8]