Advertisement

Comparison of In-Hospital Outcomes for Beta-Blocker Use Versus Non–Beta Blocker Use in Patients Presenting With Cocaine-Associated Chest Pain

      Beta blockers are indicated for management of acute coronary syndromes, but they generally are withheld in patients with cocaine-associated chest pain because of concerns for adverse outcomes related to the unique physiological effects of cocaine. Because few clinical studies have evaluated this interaction, we identified patients with toxicology screen results positive for cocaine treated for chest pain at 2 academic hospitals. Clinical characteristics and in-hospital outcomes were compared between patients with and without β-blocker therapy. We then constructed propensity scores to evaluate the independent relation between β-blocker use and the composite primary end point of myocardial infarction, stroke, ventricular arrhythmia, or all-cause mortality after adjusting for clinical characteristics. Of 376 consecutive patients with cocaine-related chest pain, β blockers were used in 164 (44%). Compared with no β blockers, patients treated with β blockers were more likely to describe anginal chest pain, to have known cardiovascular risk factors, and to receive other antiatherosclerotic therapies. Despite these higher risk clinical characteristics, patients treated with β blockers experienced similar peak troponin levels, individual adverse events, and rates of the composite primary end point (15.9% vs 12.3%, p = 0.32). The primary end point also was similar after propensity score analysis (odds ratio 1.37, 95% confidence interval 0.64 to 2.93, p = 0.42), including specific comparisons of beta-1 selective (odds ratio 1.83, 95% confidence interval 0.79 to 4.24) and nonselective (odds ratio 0.90, 95% confidence interval 0.33 to 2.42) β blockers, when compared with patients not receiving β blockers. In conclusion, no differences in outcomes were observed between patients treated versus not treated with β-blocker therapy in the setting of cocaine-related chest pain.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Rangel C.
        • Shu R.G.
        • Lazar L.D.
        • Vittinghoff E.
        • Hsue P.Y.
        • Marcus G.M.
        Beta-blockers for chest pain associated with recent cocaine use.
        Arch Intern Med. 2010; 170: 874-879
        • Dattilo P.B.
        • Hailpern S.M.
        • Fearon K.
        • Sohal D.
        • Nordin C.
        Beta-blockers are associated with reduced risk of myocardial infarction after cocaine use.
        Ann Emerg Med. 2008; 51: 117-125
        • Ibrahim M.
        • Maselli D.J.
        • Hasan R.
        • Hamilton A.
        Safety of beta-blockers in the acute management of cocaine-associated chest pain.
        Am J Emerg Med. 2012; 31: 613-616
      1. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
        Circulation. 2005; 112: IV1-203
        • Antman E.M.
        • Anbe D.T.
        • Armstrong P.W.
        • Bates E.R.
        • Green L.A.
        • Hand M.
        • Hochman J.S.
        • Krumholz H.M.
        • Kushner F.G.
        • Lamas G.A.
        • Mullany C.J.
        • Ornato J.P.
        • Pearle D.L.
        • Sloan M.A.
        • Smith Jr., S.C.
        • Alpert J.S.
        • Anderson J.L.
        • Faxon D.P.
        • Fuster V.
        • Gibbons R.J.
        • Gregoratos G.
        • Halperin J.L.
        • Hiratzka L.F.
        • Hunt S.A.
        • Jacobs A.K.
        ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction).
        Circulation. 2004; 110: e82-292
        • McCord J.
        • Jneid H.
        • Hollander J.E.
        • de Lemos J.A.
        • Cercek B.
        • Hsue P.
        • Gibler W.B.
        • Ohman E.M.
        • Drew B.
        • Philippides G.
        • Newby L.K.
        Management of cocaine-associated chest pain and myocardial infarction: a scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology.
        Circulation. 2008; 117: 1897-1907
      2. Thomas HL. “Chapter 12. Chest discomfort” (Chapter). In: Fauci AS BE, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J, ed. Harrison's Principles of Internal Medicine, 18th ed., 2011.

        • Antman E.M.
        • Cohen M.
        • Bernink P.J.
        • McCabe C.H.
        • Horacek T.
        • Papuchis G.
        • Mautner B.
        • Corbalan R.
        • Radley D.
        • Braunwald E.
        The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making.
        JAMA. 2000; 284: 835-842
        • Austin P.C.
        The performance of different propensity-score methods for estimating relative risks.
        J Clin Epidemiol. 2008; 61: 537-545
        • Austin P.C.
        The relative ability of different propensity score methods to balance measured covariates between treated and untreated subjects in observational studies.
        Med Decis Making. 2009; 29: 661-677
        • Rosenbaum P.R.
        The central role of the propensity score in observational studies for causal effects.
        Biometrika. 1983; 70: 41-55
        • Muscholl E.
        Effect of cocaine and related drugs on the uptake of noradrenaline by heart and spleen.
        Br J Pharmacol Chemother. 1961; 16: 352-359
        • Whitby L.G.
        • Hertting G.
        • Axelrod J.
        Effect of cocaine on the disposition of noradrenaline labelled with tritium.
        Nature. 1960; 187: 604-605
        • Foltin R.W.
        • Ward A.S.
        • Haney M.
        • Hart C.L.
        • Collins E.D.
        The effects of escalating doses of smoked cocaine in humans.
        Drug Alcohol Depend. 2003; 70: 149-157
        • Kugelmass A.D.
        • Oda A.
        • Monahan K.
        • Cabral C.
        • Ware J.A.
        Activation of human platelets by cocaine.
        Circulation. 1993; 88: 876-883
        • Moliterno D.J.
        • Lange R.A.
        • Gerard R.D.
        • Willard J.E.
        • Lackner C.
        • Hillis L.D.
        Influence of intranasal cocaine on plasma constituents associated with endogenous thrombosis and thrombolysis.
        Am J Med. 1994; 96: 492-496
        • Rezkalla S.H.
        • Mazza J.J.
        • Kloner R.A.
        • Tillema V.
        • Chang S.H.
        Effects of cocaine on human platelets in healthy subjects.
        Am J Cardiol. 1993; 72: 243-246
        • Rinder H.M.
        • Ault K.A.
        • Jatlow P.I.
        • Kosten T.R.
        • Smith B.R.
        Platelet alpha-granule release in cocaine users.
        Circulation. 1994; 90: 1162-1167
        • Stenberg R.G.
        • Winniford M.D.
        • Hillis L.D.
        • Dowling G.P.
        • Buja L.M.
        Simultaneous acute thrombosis of two major coronary arteries following intravenous cocaine use.
        Arch Pathol Lab Med. 1989; 113: 521-524
        • Tazelaar H.D.
        • Karch S.B.
        • Stephens B.G.
        • Billingham M.E.
        Cocaine and the heart.
        Hum Pathol. 1987; 18: 195-199
        • Ramoska E.
        • Sacchetti A.D.
        Propranolol-induced hypertension in treatment of cocaine intoxication.
        Ann Emerg Med. 1985; 14: 1112-1113
        • Rappolt Sr., R.T.
        • Gay G.
        • Inaba D.S.
        • Rappolt N.
        • Rappolt Jr., R.T.
        Use of Inderal (propranolol-Ayerst) in I-a (early stimulative) and I-b (advanced stimulative) classification of cocaine and other sympathomimetic reactions.
        Clin Toxicol. 1978; 13: 325-332
        • Rappolt R.T.
        • Gay G.
        • Inaba D.S.
        • Rappolt N.R.
        Propranolol in cocaine toxicity.
        Lancet. 1976; 2: 640-641
        • Smith M.
        • Garner D.
        • Niemann J.T.
        Pharmacologic interventions after an LD50 cocaine insult in a chronically instrumented rat model: are beta-blockers contraindicated?.
        Ann Emerg Med. 1991; 20: 768-771
        • Vargas R.
        • Gillis R.A.
        • Ramwell P.W.
        Propranolol promotes cocaine-induced spasm of porcine coronary artery.
        J Pharmacol Exp Ther. 1991; 257: 644-646
        • Das G.
        Cardiovascular effects of cocaine abuse.
        Int J Clin Pharmacol Ther Toxicol. 1993; 31: 521-528
        • Om A.
        • Ellahham S.
        • DiSciascio G.
        Management of cocaine-induced cardiovascular complications.
        Am Heart J. 1993; 125: 469-475
        • Hollander J.E.
        • Hoffman R.S.
        Cocaine-induced myocardial infarction: an analysis and review of the literature.
        J Emerg Med. 1992; 10: 169-177