To the Editor:
Cocaine use has risen exponentially in all European countries, particularly Spain and the United Kingdom, with a prevalence of users per capita very similar to that of the United States.1 The fact that cocaine use has become more widespread among Spanish youth is a matter of major concern.2 As a result, the number of users treated in hospital emergency rooms for medical problems resulting from acute intoxication,3 such as chest pain,4 has increased. The extent of the problem in terms of chronic effects, particularly cardiovascular effects,5 remains to be seen; these effects are likely to be associated with coronary disease.6,7
We have read with interest the consensus document on the use of beta-blockers written by a task force of the European Society of Cardiology and published in the Revista Española de Cardiología,8 and would like to point out that no mention was made that these medications are contraindicated when an acute cardiac condition coexists with cocaine intoxication or overdose.
In the case of acute coronary syndrome associated with cocaine use, vasospasms worsen in hypertensive patients treated with propranolol.9 Labetalol and esmolol are not effective, and alpha-adrenergic stimulation may actually exacerbate vasospasm and hypertension.10,11 Hence, benzodiazepines, nitroglycerin, and aspirin are recommended as first-line drugs. Alpha-adrenergic receptors (phentolamine) and calcium blockers (verapamil) would be used for second-line hypertension therapy. In cases of ST segment elevation, primary percutaneous coronary angioplasty is recommended over fibrinolysis, which has a higher incidence of coronary vasospasm and a greater risk of bleeding in other organs.4
As toxicologists and emergency room physicians, we consider that the attending physician should take this contraindication into consideration not only in patients first seen for an acute coronary syndrome, but also in patients whose clinical condition deteriorates after initiating standard treatment that includes beta-blockers.12