Clinical question: Are beta-blockers safe to use in patients with chest pain and recent cocaine use?
Background: Beta-blockers are known to improve outcomes after myocardial infarction, yet are contraindicated in chest pain associated with recent cocaine use. Recommendations against beta-blocker use in the setting of cocaine-induced chest pain are based on case reports, small human experiments, and the theoretical concern that beta-blockers may potentiate cocaine toxicity by creating unopposed alpha-adrenergic stimulation. Clinical outcomes of beta-blocker use in patients with cocaine use and chest pain are unknown.
Study design: Retrospective cohort study.
Setting: San Francisco General Hospital, San Francisco.
Synopsis: Three hundred thirty-one patients with chest pain and positive urine toxicologic screening for cocaine were admitted during the study period. One hundred fifty-one (46%) received a beta-blocker in the ED, per the discretion of the treating physicians. There were no differences in ECG abnormalities, troponin levels, length of stay, intubation, ventricular arrhythmias, use of vasopressors, or death in those patients who did and who did not receive a beta-blocker. Over a median follow-up of 972 days, patients who had been discharged on a beta-blocker did have a significant reduction in cardiovascular death (hazard ratio 0.29, 95% CI, 0.09-0.98, P=0.047).
Because this was an observational study and post-discharge data were limited only to vital status, definitive conclusions regarding the safety of beta-blockers in cocaine-associated chest pain cannot be made. The authors acknowledge that more rigorous study is indicated given the potential benefit of beta-blockers in this population.
Bottom line: Use of beta-blockers in patients with chest pain and positive urine drug screen for cocaine is not associated with immediate adverse outcomes and might actually reduce cardiovascular mortality over time.
Citation: Rangel C, Shu RG, Lazar LD, Vittinghoff E, Hsue PY, Marcus GM. Beta-blockers for chest pain associated with recent cocaine use. Arch Intern Med. 2010;170(10):874-879.
Reviewed for TH eWire by Kelly Cunningham MD, Joshua LaBrin, MD, Amanda Salanitro, MD, MSPH, Kelly Sopko, MD, Shelley Ellis, MD, MPH, and Elizabeth Rice MD, Section of Hospital Medicine, Vanderbilt University.
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