Study: Benefits of beta-blockers outweigh risks in cocaine users with HFrEF

Active cocaine users with heart failure with reduced ejection fraction (HFrEF) benefited from beta-blocker therapy in a recent study, seeing improved left ventricular ejection fraction (LVEF) and reduced rates of cocaine-related CV events despite long-standing worries that the treatment might exacerbate symptoms of HF.

Beta-blocker therapy is routine in HFrEF patients, Persio D. Lopez, MD, and colleagues explained in the International Journal of Cardiology. But illicit drug use complicates things—it precipitates 5 percent of cases of acute decompensation in those with HFrEF, according to the authors—and cocaine in particular is complex.

“Current guidelines recommend caution when using beta-blockers in the chronic setting, and it has been suggested they should be avoided altogether in patients with HF who use cocaine,” Lopez et al. wrote. “Recent research, however, suggests that the excessive alpha-stimulation phenomenon may be unrelated to beta-blocker therapy. In addition, clinical and echocardiographic improvement has been reported in patients with HF who use cocaine and received beta-blocker therapy, without an increase in HF readmissions, cardiovascular events or mortality.”

Lopez’s team performed a retrospective analysis of 72 beta-blocker-naive patients with HFrEF who were active cocaine users, hypothesizing that those who were prescribed beta-blockers would experience better outcomes.

The authors said it isn’t standard procedure at their New York hospital to extend beta-blocker therapy to those actively using cocaine, but their study cohort consisted largely of patients who had either initially lied about their drug use or committed to quitting cocaine but relapsed. Those patients were prescribed beta-blockers before routine urine tests determined they were still active users.

At the study’s baseline, 55.5 percent of patients in the beta-blocker therapy group and 55.9 percent of patients in the control group were either New York Heart Association functional class (NYHA-FC) III or IV, Lopez and co-authors reported. After 12 months of treatment, 52.6 percent of individuals in the beta-blocker group saw an improvement in their NYHA-FC compared to 23.5 percent of people in the control group, and nearly three-quarters of patients in the study group were classified as either NYHA-FC I or II by the end of the study.

Patients on beta-antagonists were also more likely to see an improvement in their LVEF, which was the same in both groups at the study’s baseline. Almost 58 percent of patients in the study group had an improvement after a year of therapy (compared with 23.5 percent of the control group), and 36.9 percent of patients who received beta-blocker therapy had an LVEF of 40 percent by the end of the study (compared to 20 percent of control patients).

Lopez et al. reported patients taking beta-blockers also saw a lower risk of cocaine-related cardiovascular events and heart failure hospitalizations than controls.

Though the study’s findings were positive, a team of physicians led by Andrea Barison, MD, PhD, noted some of the trial’s shortcomings in an editorial published simultaneously in IJC.

“The small number of patients and the retrospective nature of the study represent major limitations, particularly because beta-blockers were not randomly prescribed, nor was a correction with propensity score matching performed, so that a ‘treatment bias’ may be present,” Barison and co-authors wrote. “Moreover, information about therapy adherence was lacking, as well as about the amount and route of cocaine use; this is a crucial point for all studies on illicit drug assumption.”

Barison et al. also criticized the study’s failure to include cardiovascular MRI as a way to investigate the presence and extent of any myocardial fibrosis or edema, as well as the fact that coronary angiography was performed in the majority of patients, but not all of them, leaving a hole in the dataset.

“Overall, the study by Lopez suggests that beta-blocker therapy is generally safe and effective in cocaine addicts with HFrEF, but their results are not conclusive,” they wrote.