In reply
We appreciate the comments provided by Canning et al. While we agree that it is possible that patients with cocaine-related chest pain with greater sympathomimetic activity may react differently to BB administration, we found no evidence of this in our study. In addition, the blood pressure response on average was substantially reduced after BBs were given, with no evidence that the BBs induced any hypertensive urgencies or emergencies. Canning et al raise an important issue related to methamphetamine use. While the pathophysiologic changes and response to BBs may be similar to those with recent cocaine ingestion, our study did not address the safety of BBs in the setting of methamphetamine use. Future studies aimed at elucidating the risks (and potential benefits) of BBs in cocaine and/or amphetamine users with different levels of sympathomimetic-induced toxicity will indeed be important. Finally, we agree that there is likely little downside to using nonselective BBs, such as carvedilol, in these patients. However, cost, the availability of intravenous formulations, potential differences in blood pressure response, and, if prescribing for long-term outpatient use, differences in tolerability should be considered.