Patients with NSTE-ACS and a recent history of cocaine or methamphetamine use should be treated Amsterdam et al 2014 AHA/ACC NSTE-ACS Guideline e391 in the same manner as patients without cocaine- or methamphetamine-related NSTE-ACS. The only ex- ception is in patients with signs of acute intoxication (eg, euphoria, tachycardia, and/or hypertension) and beta-blocker use, unless patients are receiving coro- nary vasodilator therapy. (Level of Evidence: C) Class IIa 1. Benzodiazepines alone or in combination with nitro- glycerin are reasonable for management of hyperten- sion and tachycardia in patients with NSTE-ACS and signs of acute cocaine or methamphetamine intoxica- (Level of Evidence: C) Class III: Harm 1. Beta blockers should not be administered to patients with ACS with a recent history of cocaine or metham- phetamine use who demonstrate signs of acute intoxi- cation due to the risk of potentiating coronary spasm. (Level of Evidence: C) Cocaine exerts multiple effects on the cardiovascular system, which may precipitate ACS.48,744,745 Acute cocaine exposure results in increased BP, heart rate, endothelial dysfunction, and platelet aggregation, all of which may precipitate ACS. Cocaine s direct vasoconstrictor effect can produce coronary vasospasm. Long-term use of cocaine results in progressive myocyte damage and accelerated atherosclerosis.48,744,745 ACS in patients with a history of cocaine use should be treated in the same manner as patients without cocaine use.744 The exception is in patients with ACS in the presence of acute cocaine intoxication. 