UMEM Educational Pearls

Category: Toxicology

Title: Treatment of Acute Cocaine Cardiovascular Toxicity

Keywords: cocaine, toxicity, cardiovascular (PubMed Search)

Posted: 3/9/2016 by Bryan Hayes, PharmD (Emailed: 3/10/2016) (Updated: 3/12/2016)
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Acute cocaine toxicity can manifest with several cardiovascular issues such as tachycardia, dysrhythmia, hypertension, and coronary vasospasm. A new systematic review collated all of the available evidence for potential treatment options. Here is what the review found (there is also an 'other agents' section for medications with less published reports):

  • Benzodiazepines and other GABA-active agents: Benzodiazepines may not always effectively mitigate tachycardia, hypertension, and vasospasm from cocaine toxicity.

  • Calcium channel blockers: Calcium channel blockers may decrease hypertension and coronary vasospasm, but not necessarily tachycardia.

  • Nitric oxide-mediated vasodilators: Nitroglycerin may lead to severe hypotension and reflex tachycardia.

  • Alpha-adrenoceptor blocking drugs: Alpha-1 blockers may improve hypertension and vasospasm, but not tachycardia, although evidence is limited.

  • Alpha-2-adrenoceptor agonists: There were two high-quality studies and one case report detailing the successful use of dexmedetomidine.

  • Beta-blockers and alpha/beta-blockers: No adverse events were reported for use of combined alpha/beta-blockers such as labetalol and carvedilol, which were effective in attenuating both hypertension and tachycardia.

  • Antipsychotics: Antipsychotics may improve agitation and psychosis, but with inconsistent reduction in tachycardia and hypertension and risk of extrapyramidal adverse effects.

  • Sodium bicarbonate: Twelve case reports documented treatment of dysrhythmia with IV sodium bicarbonate, with seven reporting successful termination.

The authors note that "publication bias is a concern, and it is possible that successful treatment and/or adverse events have not been reported in some of the publications, and in general."


Richard JR, et al. Treatment of cocaine cardiovascular toxicity: a systematic review. Clin Toxicol. 2016 Feb 26:1-20. [Epub ahead of print] [PMID 26919414]

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