Which should NEVER be used in the treatment of cocaine-associated chest pain?

• A. Nitrates
• B. Beta blockers
• C. Calcium channel blockers
• D. Aspirin

Answer: (B)

Cocaine-associated chest pain is driven by a surge of sympathetic activity that causes tachycardia, hypertension, and coronary vasospasm. The treatment goal is to reduce sympathetic drive and promote vasodilation. Beta blockers blunt the heart’s response but do not address the cocaine-induced vasoconstriction mediated by alpha-adrenergic receptors. When beta receptors are blocked, the increased norepinephrine from cocaine can cause unopposed alpha-adrenergic stimulation, leading to worse vasoconstriction, higher blood pressure, and potentially more severe chest pain or ischemia. That’s why using beta blockers alone is avoided in this setting.

Instead, you treat with agents that reduce sympathetic tone and vasospasm: benzodiazepines to calm the patient and lower sympathetic output, nitrates to dilate coronary vessels, and calcium channel blockers for additional vasodilation and rate control as needed. If antiplatelet therapy is indicated for suspected ACS, aspirin is used. In some cases, alpha–beta blockers like labetalol (which block both types of receptors) can be considered, but pure beta blockade alone is not recommended.