Abstract
Introduction
Although it is commonly stated that the use of beta adrenergic receptor antagonists is contraindicated in patients with cocaine toxicity, actual clinical evidence of harm is lacking. This case helps to highlight the risks of beta adrenergic receptor antagonists in patients with chest pain associated with cocaine use.
Case Report
A 54-year-old man was brought to the emergency department (ED) complaining of chest pain after using approximately 1 gram of intranasal cocaine. Aspirin and nitroglycerin spray relieved his pain. Although he remained pain free, tachycardia persisted despite 15 mg of diazepam intravenously. Nearly two hours after presentation, a total of 5 mg of metoprolol was given for persistent tachycardia (115/minute) and an elevated troponin. Shortly thereafter, the patient complained of crushing substernal chest pain, developed pulseless electrical activity, and could not be resuscitated.
Discussion
The administration of beta adrenergic receptor antagonists exacerbates cocaine-induced lethality in animals. In humans given smaller doses of cocaine, beta adrenergic receptor antagonists exacerbate coronary vasoconstriction. Both effects are presumed to occur through unopposed alpha adrenergic receptor agonism. Despite these data, actual cases describing adverse effects in cocaine users given beta adrenergic receptor antagonists are uncommon. This case supports the potential lethality of a cocaine-beta adrenergic receptor antagonist interaction.
Article PDF
Similar content being viewed by others
References
Lange RA, Hillis LD. Cardiovascular complications of cocaine use.N Engl J Med 2001;345:351–358.
Brody SL, Slovis CM, Wrenn KD. Cocaine-related medical problems: Consecutive series of 233 patients.Am J Med. 1990;88:325–331.
Qureshi AI, Suri MF, Guterman LR, Hopkins LN. Cocaine use and the likelihood of nonfatal myocardial infarction and stroke: Data from the third national health and nutrition examination survey.Circulation.2001;103:502–506.
National Quality Measures Clearinghouse: Acute myocardial infarction: percent of patients without beta blocker contraindications who received a beta blocker within 24 hours after hospital arrival. Accessed September1, 2007. Available at: http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?doc_id=6054
Joint Commission on Accreditation of Healthcare Organizations. Beta Blockers For Acute Myocardial Infarction. Accessed 2/1/07. Available at: http://www.jointcommission.org/ NR/rdonlyres/AB92B013-B9A7-48AC-8AC6-759410D6E791/0/ COMMITBetaBlockerFACTSheet.pdf
Rappolt RT, Gay G, Inaba DS, Rappolt NR. Propranolol in cocaine toxicity.Lancet.1976;2(7986):640–641.
Rappolt RT, Gay GR, Inaba DS. Propranolol: a specific antagonist to cocaine.Clin Toxicol. 1977;10:265–271.
Rappolt RT Sr, Gay G, Inaba DS, Rappolt N, Rappolt RT Jr. 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.
Guinn MM, Bedford JA, Wilson MC. Antagonism of intravenous cocaine lethality in nonhuman primates.Clin Toxicol. 1980;16:499–508.
Catravas JD, Waters IW. Acute cocaine intoxication in the conscious dog: Studies on the mechanism of lethality.J Pharmacol Exp Ther. 1981;217:350–356.
Lange RA, Cigarroa RG, Flores ED, McBride W, Kim AS, Wells PJ, Bedotto JB, Danziger RS, Hillis LD. Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade.Ann Intern Med. 1990;112:897–903.
Lange RA, Cigarroa RG, Yancy CW, Jr, Willard JE, Popma JJ, Sills MN, McBride W, Kim AS, Hillis LD. Cocaine-induced coronary-artery vasoconstriction.N Engl J Med. 1989;321:1557–1562.
Boehrer JD, Moliterno DJ, Willard JE, Hillis LD, Lange RA. Influence of labetalol on cocaine-induced coronary vasoconstriction in humans.Am J Med. 1993;94:608–610.
Gay GR, Loper KA. The use of labetalol in the management of cocaine crisis.Ann Emerg Med. 1988;17:282–283.
Sand IC, Brody SL, Wrenn KD, Slovis CM. Experience with esmolol for the treatment of cocaine-associated cardiovascular complications.Am J Emerg Med. 1991;9:161–163.
Merigian KS, Park LJ, Leeper KV, Browning RG, Giometi R. Adrenergic crisis from crack cocaine ingestion: report of five cases.J Emerg Med. 1994;12:485–490.
Blaho K, Winbery S, Park L, Gresham HW. Cocaine use and acute coronary syndromes.Lancet.2001;358(9290):1368.
O’Brien TP, Pane MA, Traystman RJ, Gleason CA. Propranolol blocks cocaine-induced cerebral vasodilation in newborn sheep.Crit Care Med. 1999;27:784–789.
Leikin JB. Cocaine and beta-adrenergic blockers: a remarriage after a decade-long divorce?Crit Care Med. 1999;27:688–689.
Robinson R, Iida H, O’Brien TP, Pane MA, Traystman RJ, Gleason CA. Comparison of cerebrovascular effects of intravenous cocaine injection in fetal, newborn, and adult sheep.Am J Physiol Heart Circ Physiol. 2000;279:H1–6.
Albertson TE, Dawson A, de Latorre F, Hoffman RS, Hollander JE, Jaeger A, Kerns WR 2nd, Martin TG, Ross MP. TOX-ACLS: toxicologic-oriented advanced cardiac life support.Ann Emerg Med. 2001;37(4 Suppl):S78–90.
Brogan WC 3rd, Lange RA, Glamann DB, Hillis LD. Recurrent coronary vasoconstriction caused by intranasal cocaine: possible role for metabolites.Ann Intern Med. 1992;116:556–561.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Fareed, F.N., Chan, G.M. & Hoffman, R.S. Death temporally related to the use of a beta adrenergic receptor antagonist in cocaine associated myocardial infarction. J. Med. Toxicol. 3, 169–172 (2007). https://doi.org/10.1007/BF03160934
Issue Date:
DOI: https://doi.org/10.1007/BF03160934