Cocaine Chest Pain: To Beta Block or Not?

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Cocaine Chest Pain: To Beta Block or Not?

β-blockers reduced the incidence of myocardial infarction but not death in this retrospective cohort study.

Chest pain after cocaine use is a common emergency department presenting complaint. Conventional wisdom, supported by some evidence, has dictated that patients with cocaine-associated chest pain should not receive β-blockers, unlike the recommendation for β-blockers in cardiac chest-pain patients without cocaine exposure. Although a strong body of evidence supports β-blockade for patients with myocardial infarction, the theory regarding patients with cocaine exposure is that β-blockade would lead to unopposed ${alpha}$ stimulation and exacerbate the untoward cardiac effects of cocaine (which include myocardial depression and vasospasm) and would negate potential positive effects of treatment of MI and systolic dysfunction.

In a retrospective cohort study, these authors investigated the association between inpatient β-blocker administration and in-hospital MI and death. The study included all patients who were admitted to an intensive care unit or step-down unit from a single inner-city ED during a 5-year period and who tested positive for cocaine, had not taken β-blockers before admission, and had serial cardiac biomarker measurements after admission. The most common admission diagnoses were chest pain (165 patients), congestive heart failure (8), stroke (11), seizure (12), and overdose (15).

β-blockers were administered in 60 of 348 admissions involving 296 patients. The incidence of MI was significantly lower in patients who received β-blockers than in those who did not (6.1% vs. 26.0%; adjusted odds ratio, 0.06). Mortality rates did not differ significantly in the β-blocker and no–β-blocker groups (1.7% vs. 4.5%).

Comment: Although this study seemingly contradicts the current practice of withholding β-blockers in chest-pain patients with histories of cocaine use, the authors did not differentiate among presentations (i.e., acute coronary syndrome or ST-segment-elevation MI vs. rule out MI) or between cocaine toxicity and presence of cocaine metabolite, among other confounders. Questioning conventional wisdom is always fun, especially when the wisdom is based on such a paucity of evidence as is the caution against giving β-blockers to patients with cocaine-associated chest pain. However, these results must be viewed as preliminary and, until a randomized, controlled prospective study is conducted, probably should not lead to a change in practice.

— Richard D. Zane, MD, FAAEM

Published in Journal Watch Emergency Medicine February 29, 2008