A 28-year-old man is brought to the emergency department agitated and diaphoretic, with chest pain. BP is 214/122 mmHg with sinus tachycardia at 128/min. Urine toxicology is positive for benzoylecgonine. Along with benzodiazepines, which antihypertensive is CONTRAINDICATED in this patient?
- A Nicardipine infusion
- B Propranolol ✓
- C Phentolamine
- D Nitroglycerin
Correct answer: B. Propranolol
Explanation
Cocaine blocks reuptake of catecholamines, producing alpha-mediated vasoconstriction. Pure beta blockade leaves alpha stimulation unopposed, worsening vasoconstriction, hypertension and myocardial ischemia, so propranolol is contraindicated. Benzodiazepines are first line, with phentolamine for persistent severe hypertension and nitrates if ischemia persists. Mixed agents such as labetalol are also avoided by many guidelines because their beta component predominates. Phentolamine directly reverses alpha-mediated constriction.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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