Safety of β-blockers in the acute management of cocaine-associated chest pain

Background: Cocaine is the most commonly abused illegal drug in patients presenting to emergency departments (EDs) because of chest pain and accounts for almost 40% of all drug-related visits. It is not known whether all beta-blockers (BB) and beta 1-selective agents or mixed alpha 1/beta-adrenergic antagonists (alpha 1/beta-BB) are safe in the acute management of cocaine-associated chest pain, due to concerns of unopposed a-receptor activity resulting in coronary artery spasm and hypertensive urgency. Methods: Patients who presented to the EDs of 2 large inner city hospitals because of chest pain and who tested positive for cocaine were identified by retrospective chart review. Demographic characteristics, symptoms, vital signs, electrocardiographic abnormalities, medication use, comorbidities, and troponin values were documented. The presence and type of BB used were studied in relation to peak elevation in troponin T and troponin I. Troponin elevation was defined as a troponin I greater than 0.6 ng/mL and troponin T greater than 0.1 ng/mL if serum creatinine was less than 2 mg/dL. Results: A total of 378 patients were included in the study; of these, 78% (n=296) were black; 12% (n=44), white; and 10% (n = 38), of other race. Twelve percent (n = 46) of the patients had typical chest pain, 22% (n = 84) had coronary artery disease, 56% (n = 213) had hypertension, and 21% (n = 79) had diabetes mellitus. The admission electrocardiogram showed changes (ST elevation, ST depression, or T-wave inversion) in 43% (n = 163) of the patients. beta-Blockers were used in 43% (n = 162) of the encounters. Troponin elevation occurred in 11% (n = 42) of patients. There was no difference in the number of patients with troponin rise in the BB and non-BB groups, 22 of 162 vs 20 of 213 (P = .2). There was no difference in mean peak troponin levels in patients with troponin rise who were treated with BB vs no BB, 6.7 vs 5.7 ng/mL (P=.6). There was no difference in mean peak troponin levels in patients with troponin rise who were treated with a beta 1-selective agents vs a alpha 1/beta-BB, 7.5 vs 4.1 ng/mL (P = .4). No cases of hypertensive urgency were identified after taking any BB. Conclusion: Troponin rise is not uncommon in patients with cocaine-associated chest pain and occurred in 11% of the patients. In patients with cocaine-associated chest pain, BBs did not appear to change the incidence of troponin rise. beta 1-Selective BBs did not appear to worsen troponin levels compared with mixed alpha 1/beta-BB. (C) 2013 Elsevier Inc. All rights reserved.