Should beta-blockers be used in the treatment of cocaine-associated acute coronary syndrome?
OBJECTIVE
To critically evaluate the 30 year debate of beta-blocker use in cocaine-induced acute coronary syndrome (CIACS).


METHODS
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 beta-antagonists.


METHODS
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 beta-blocker was used during the treatment course, and (3) objective and subjective patient-specific information was documented.


RESULTS
Three case reports and 2 placebo-controlled trials were identified that used 4 beta-blockers (atenolol, labetalol, metoprolol, propranolol). Three national guidelines addressed beta-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 beta-blockers as first-line agents in CIACS management.


CONCLUSIONS
Beta-blockers should not be considered first-line agents for controlling chest pain in patients with documented CIACS. If long-term beta-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.
Page
Robert Lee
RL
Department of Clinical Pharmacy, School of Pharmacy, University of Colorado Health Sciences Center, Denver, CO 80045, USA. robert.page@uchsc.edu
Utz
Kenneth J
KJ
Wolfel
Eugene E
EE
D054058:Acute Coronary Syndrome / Q000139:chemically induced / Q000188:drug therapy*; D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D003042:Cocaine / Q000009:adverse effects*; D006801:Humans; D017410:Practice Guidelines as Topic
D000319:Adrenergic beta-Antagonists; D003042:Cocaine