Beta Blockers in Congestive Heart Failure Patients with Cocaine Use
Beta blockers should not be administered to patients with congestive heart failure who show signs of acute cocaine intoxication due to the risk of potentiating coronary spasm, but are safe and beneficial in heart failure patients with a history of cocaine use who are not actively intoxicated. 1
Interaction Between Beta Blockers and Cocaine
Acute Cocaine Intoxication
- Beta blockers are contraindicated in patients showing signs of acute cocaine intoxication (euphoria, tachycardia, hypertension) due to the risk of unopposed alpha-adrenergic stimulation leading to worsened coronary vasospasm 1
- Cocaine stimulates both alpha- and beta-adrenergic receptors; administration of beta blockers during acute intoxication can result in unopposed alpha stimulation with potentially dangerous vasoconstriction 1
- For patients with acute cocaine intoxication who require management of hypertension and tachycardia, benzodiazepines alone or in combination with nitroglycerin are reasonable alternatives 1
History of Cocaine Use (Without Acute Intoxication)
- Patients with heart failure and a history of cocaine use (but not acutely intoxicated) should be treated with standard heart failure therapy, including beta blockers 1, 2
- Multiple studies have shown that beta blocker therapy in heart failure patients with a history of cocaine use is associated with:
Beta Blocker Selection in Heart Failure
Recommended Beta Blockers
- For heart failure patients, including those with a history of cocaine use, the three beta blockers proven to reduce mortality should be used 1:
- Bisoprolol
- Carvedilol
- Extended-release metoprolol succinate
- Both cardioselective (metoprolol) and non-cardioselective (carvedilol) beta blockers appear to be safe in heart failure patients with a history of cocaine use 5
Initiation and Titration
- Start with a low dose and gradually titrate upward while monitoring for adverse effects 6
- Initial dosing recommendations:
- Bisoprolol: 1.25 mg daily, target 10 mg daily
- Metoprolol succinate CR: 12.5-25 mg daily, target 200 mg daily
- Carvedilol: 3.125 mg twice daily, target 25-50 mg twice daily
Clinical Evidence and Outcomes
- A systematic review found that beta blocker therapy appears to be safe and beneficial in heart failure patients with active cocaine use, with either beneficial or neutral effects on primary outcomes 7
- A retrospective analysis of 72 beta-blocker-naïve patients with heart failure and active cocaine use showed that those who received beta blockers had:
- Greater improvement in NYHA functional class (p=0.0106)
- Greater improvement in left ventricular ejection fraction (p=0.0031)
- Lower risk of cocaine-related cardiovascular events (p=0.0086)
- Lower risk of heart failure hospitalizations (p=0.0383) 3
- A 2022 study found that both selective and non-selective beta blockers may be safe in managing patients with heart failure with reduced ejection fraction and cocaine use 5
Common Pitfalls and Recommendations
- Do not confuse history of cocaine use with acute intoxication - the contraindication for beta blockers applies only to patients showing signs of acute intoxication 1
- Always assess for signs of acute cocaine intoxication (euphoria, tachycardia, hypertension) before administering beta blockers 1
- If a patient with heart failure and cocaine use requires treatment during acute intoxication, consider benzodiazepines with or without nitroglycerin for managing hypertension and tachycardia 1
- Once acute intoxication has resolved, beta blocker therapy should be initiated or resumed as part of standard heart failure management 1, 3
- Regular monitoring should include heart rate, blood pressure, and signs of worsening heart failure 6