Can beta blockers be administered to patients with a history of cocaine use who do not exhibit symptoms of chest pain, such as angina (Angina Pectoris)?

From the Guidelines

Administration of Beta Blockers in Patients with a History of Cocaine Use

Beta blockers should not be administered to patients with a history of cocaine use who do not exhibit symptoms of chest pain, such as angina, due to the risk of unopposed alpha-adrenergic stimulation and potential exacerbation of hypertension and coronary vasoconstriction 1.

• Key Considerations: The use of beta blockers in these patients may worsen coronary spasm, which can lead to acute coronary syndromes (ACS) 1.
• Alternative Therapies: In patients with ACS and a history of cocaine use, benzodiazepines alone or in combination with nitroglycerin may be useful for managing hypertension and tachycardia 1.
• Selective Beta-1 Blockers: If beta blocker therapy is deemed necessary, a cautious approach with a selective beta-1 blocker like esmolol may be considered under close monitoring 1.
• Dosing and Monitoring: The dose of esmolol should be 0.25-0.5 mg/kg IV bolus, followed by an infusion of 0.05-0.1 mg/kg/min, with the duration of therapy limited to the minimum required to achieve clinical stability 1.
• Guideline Recommendations: The 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes recommends avoiding beta blockers in patients with signs of acute cocaine intoxication 1.
• European Society of Cardiology (ESC) Guidelines: The 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation also recommend avoiding beta blockers in patients with symptoms possibly related to coronary vasospasm or cocaine use 1.

From the Research

Administration of Beta Blockers to Patients with a History of Cocaine Use

• The use of beta blockers in patients with a history of cocaine use is a topic of debate due to the potential risk of unopposed α-adrenergic stimulation and coronary vasospasm 2, 3.
• A meta-analysis of five studies evaluating 1794 subjects found no significant difference in non-fatal myocardial infarction (MI) and all-cause mortality in patients with cocaine-associated chest pain (CACP) on beta blockers versus no beta blockers 2.
• Another study suggested that beta blockers should not be considered first-line agents for controlling chest pain in patients with documented cocaine-induced acute coronary syndrome (CIACS), but carvedilol may be considered due to its ancillary pharmacologic properties beneficial in CIACS 3.
• A systematic review of 12 studies found that beta blockers had either a beneficial or neutral effect on primary outcomes in heart failure patients with active cocaine use, although the evidence is not robust 4.

Safety and Efficacy of Beta Blockers

• Beta-1 selective blockers have been shown to lower systolic and diastolic blood pressure in people with primary hypertension, with an average reduction of -10/-8 mmHg and a reduction in heart rate by 11 beats per minute 5.
• The use of beta blockers with intrinsic sympathomimetic activity (ISA) may offer some advantages over conventional beta blockers in hypertensive patients with concurrent conditions such as chronic obstructive airways disease, peripheral vascular disease, diabetes, and hyperlipidemia 6.

Considerations for Patients without Symptoms of Chest Pain

• There is limited evidence specifically addressing the administration of beta blockers to patients with a history of cocaine use who do not exhibit symptoms of chest pain, such as angina (Angina Pectoris) 2, 3, 4.
• However, the available evidence suggests that beta blockers may be safe and effective in patients with a history of cocaine use, even in the absence of chest pain symptoms, although caution and careful consideration of individual patient factors are necessary 2, 3, 4.