Management of Cocaine-Induced Hypertension

First-Line Treatment

The American Heart Association recommends benzodiazepines as the first-line treatment for cocaine-induced hypertension and tachycardia, by reducing sympathetic outflow and treating the underlying agitation 1, 3, 2
Benzodiazepines effectively control blood pressure, heart rate, and reduce coronary vasospasm through anxiolysis and sedation 1, 3, 2
Diazepam specifically demonstrated improved autonomic findings and resolution of chest pain in cocaine-associated presentations 1, 4

The American College of Cardiology suggests phentolamine is the preferred traditional antihypertensive as it directly reverses cocaine-induced coronary artery vasospasm and hypertension without risk of unopposed alpha-stimulation 1, 4
Verapamil effectively resolves cocaine-induced coronary vasospasm and hypertension, and may be used as a safer alternative when alpha-blockers are unavailable 1, 5, 6
Nitroglycerin reverses cocaine-induced coronary vasospasm and reduces blood pressure, but should be used with caution due to the risk of severe hypotension and reflex tachycardia 1, 7, 4

The American Heart Association states that pure beta-blockers are contraindicated in acute cocaine intoxication due to the risk of unopposed alpha-stimulation causing paradoxical hypertension and severe coronary vasospasm 3, 2
Propranolol worsened cocaine-induced coronary artery vasoconstriction in clinical trials, and esmolol showed no consistent improvement and caused adverse effects 1, 7, 4, 8, 5

The International Consensus recommends immediate management with benzodiazepines, followed by phentolamine, verapamil, or nitroglycerin if hypertension persists, and avoidance of pure beta-blockers entirely in the acute setting 1, 3, 2, 8, 7
For coronary vasospasm or chest pain, nitroglycerin plus benzodiazepines may be used, with consideration of phentolamine or verapamil if nitroglycerin is ineffective 1, 4

The American College of Cardiology suggests that for chronic hypertension in patients with a history of cocaine use, standard antihypertensives can be used once acute effects have resolved, and addressing underlying substance use disorder with naltrexone may reduce cocaine craving and prevent relapse 3