β-Blockers for Chest Pain Associated With Recent Cocaine Use

Abstract

Although beta-blockers prevent adverse events after myocardial infarction, they are contraindicated when chest pain is associated with recent cocaine use. Recommendations against this use of beta-blockers are based on animal studies, small human experiments, and anecdote. We sought to test the hypothesis that beta-blockers are safe in this setting. We performed a retrospective cohort study of consecutive patients admitted to the San Francisco General Hospital, San Francisco, California, with chest pain and urine toxicologic test results positive for cocaine, from January 2001 to December 2006. Mortality data were collected from the National Death Index. Of 331 patients with chest pain in the setting of recent cocaine use, 151 (46%) received a beta-blocker in the emergency department. There were no meaningful differences in electrocardiographic changes, troponin levels, length of stay, use of vasopressor agents, intubation, ventricular tachycardia or ventricular fibrillation, or death between those who did and did not receive a beta-blocker. After adjusting for potential confounders, systolic blood pressure significantly decreased a mean 8.6 mm Hg (95% confidence interval, 14.7-2.5 mm Hg) in those receiving a beta-blocker in the emergency department compared with those who received their first beta-blocker in the hospital ward (P = .006). Over a median follow-up of 972 days (interquartile range, 555-1490 days), after adjusting for potential confounders, patients discharged on a beta-blocker regimen exhibited a significant reduction in cardiovascular death (hazard ratio, 0.29; 95% confidence interval, 0.09-0.98) (P = .047). beta-Blockers do not appear to be associated with adverse events in patients with chest pain with recent cocaine use.