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DRUG INFORMATION ROUNDS

Should ß-Blockers Be Used in the Treatment of Cocaine-Associated Acute Coronary Syndrome?

Associate Professor, Departments of Clinical Pharmacy and Physical Medicine, Schools of Pharmacy and Medicine, University of Colorado Health Sciences Center, Denver, CO

Kenneth J Utz, PharmD

Pharmacy Practice Resident, Department of Pharmacy, University of Colorado Hospital

Eugene E Wolfel, MD FACC FACSM

Professor of Medicine, Division of Cardiology, Department of Medicine, School of Medicine, University of Colorado Health Sciences Center

Reprints: Dr. Page, School of Pharmacy, UCDHSC, C238-L15 Academic Office 1, 12631 E. 17th Ave., Room L15-1415, PO Box 6511, Aurora, CO 80045, fax 303/724-2627, robert.page{at}uchsc.edu

OBJECTIVE: To critically evaluate the 30 year debate of ß-blocker use in cocaine-induced acute coronary syndrome (CIACS).

DATA SOURCES: An Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, and Ovid MEDLINE (1966–August 21, 2007) search of the medical literature was conducted using the key terms cocaine, myocardial infarction, acute coronary syndrome, and adrenergic ß-antagonists.

STUDY SELECTION AND DATA EXTRACTION: All clinical trials, case reports, national cardiovascular guidelines, and reviews published in English were evaluated. Case reports were included based on whether (1) acute coronary syndrome was suspected, (2) a ß-blocker was used during the treatment course, and (3) objective and subjective patient-specific information was documented.

DATA SYNTHESIS: Three case reports and 2 placebo-controlled trials were identified that used 4 ß-blockers (atenolol, labetalol, metoprolol, propranolol). Three national guidelines addressed ß-blocker use. Although published data are limited, propranolol and labetalol exert minimal to no effect on alleviating cocaine-induced coronary vasoconstriction. None of the evaluated national guidelines recommends ß-blockers as first-line agents in CIACS management.

CONCLUSION: ß-Blockers should not be considered first-line agents for controlling chest pain in patients with documented CIACS. If long-term ß-blockade is warranted, its benefits should be weighed against recurrent use of cocaine and possible exacerbation of acute coronary syndrome. Given that carvedilol exhibits ancillary pharmacologic proprieties beneficial in CIACS, and post-myocardial infarction mortality data are available regarding its use, this agent could be considered to be appropriate therapy.

Key Words: acute coronary syndrome, ß-blockers, cocaine

Published Online, October 23, 2007. www.theannals.com, DOI 10.1345/aph.1H643