Contributor: Chris Holmes, MD Educational Pearls: Many are taught that patients with cocaine chest pain should not receive beta-blockers due to unopposed alpha agonism, but is this true? 363 consecutive admissions for chest pain with positive cocaine on urine toxicology were reviewed in a retrospective cohort study 60 patients in this cohort received a beta-blocker and multivariate analysis demonstrated a reduction in myocardial infarction risk Another retrospective cohort study demonstrated no association of negative outcomes with beta-blocker administration in those with a recent positive result on cocaine urine toxicology Two more recent meta-analyses were performed finding no association between adverse clinical outcomes and beta-blocker administration for cocaine chest pain No prospective randomized-controlled trials have been performed to evaluate the use of beta-blockers for treatment of cocaine chest pain in the ED setting References Dattilo PB, Hailpern SM, Fearon K, Sohal D, Nordin C. Beta-blockers are associated with reduced risk of myocardial infarction after cocaine use [published correction appears in Ann Emerg Med. 2008 Jul;52(1):90]. Ann Emerg Med. 2008;51(2):117-125. doi:10.1016/j.annemergmed.2007.04.015 Rangel C, Shu RG, Lazar LD, Vittinghoff E, Hsue PY, Marcus GM. Beta-blockers for chest pain associated with recent cocaine use. Arch Intern Med. 2010;170(10):874-879. doi:10.1001/archinternmed.2010.115 Pham D, Addison D, Kayani W, et al. Outcomes of beta blocker use in cocaine-associated chest pain: a meta-analysis. Emerg Med J. 2018;35(9):559-563. doi:10.1136/emermed-2017-207065 Lo KB, Virk HUH, Lakhter V, et al. Clinical Outcomes After Treatment of Cocaine-Induced Chest Pain with Beta-Blockers: A Systematic Review and Meta-Analysis. Am J Med. 2019;132(4):505-509. doi:10.1016/j.amjmed.2018.11.041 Richards JR, Hollander JE, Ramoska EA, et al. β-Blockers, Cocaine, and the Unopposed α-Stimulation Phenomenon. J Cardiovasc Pharmacol Ther. 2017;22(3):239-249. doi:10.1177/1074248416681644 Lange RA, Cigarroa RG, Flores ED, et al. Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade. Ann Intern Med. 1990;112(12):897-903. doi:10.7326/0003-4819-112-12-897 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD   The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today!