What is the role of beta-blockers in the treatment of cocaine toxicity?

Updated: Dec 31, 2020
  • Author: Lynn Barkley Burnett, MD, EdD, JD; Chief Editor: Sage W Wiener, MD  more...
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The 2014 ACCF/AHA guidelines on unstable angina and non–ST-segment elevation myocardial infarction advise that the use of beta-blockers within 4 to 6 hours after cocaine exposure is controversial, with some evidence for harm. Instead, the guidelines recommend that a combined alpha- and beta-blocking agent (eg, labetalol) may be a reasonable treatment choice for cocaine-related hypertension (systolic blood pressure > 150 mm Hg) or sinus tachycardia (pulse > 100 beats per min), provided that the patient has received a vasodilator, such as nitroglycerin or a calcium channel blocker, within the past hour. [47]

However, labetalol has an alpha-to-beta blockade ratio of 1:7. Therefore, it may not provide cocaine-toxic patients with enough protection from (relatively) unopposed alpha stimulation. Its risk of exacerbating myocardial ischemia parallels the risk of beta-blockers. Labetalol also increased seizures and mortality in animal models. Nevertheless, a systematic review of cocaine-related cardiovascular toxicity found that combined alpha/beta-blockers such as labetalol and carvedilol were effective in attenuating both hypertension and tachycardia, with no adverse events reported. [54]

AHA guidelines for cardiopulmonary resuscitation and emergency cardiovascular care advise that pure beta-blockers are not indicated for the treatment of cocaine-related cardiac toxicity. [46]

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