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. Because cocaine stimulates both alpha- and beta-adrenergic receptors, administration of intravenous beta blockers may result in unopposed alpha stimulation with worsening coronary spasm.48,132,744 746 Evidence suggests it is safe to administer intravenous beta blockers in patients with chest pain and recent cocaine ingestion, although information is lacking about the effects of beta-blocker administration dur- ing the acute stages of cocaine intoxication.747,748 Intravenous beta blockers should be avoided in patients with NSTE-ACS with signs of acute cocaine intoxication (euphoria, tachycar- dia, and/or hypertension). In these patients, benzodiazepines alone or in combination with nitroglycerin have been useful for management of hypertension and tachycardia owing to their effects on the central and peripheral manifestations of acute cocaine intoxication.741 744 Methamphetamine abuse is becoming increasingly com- mon in the United States owing to the ease of manufactur- ing and the lower cost of methamphetamines compared with Methamphetamines may be ingested orally, inhaled, or used intravenously. Methamphetamine affects the central nervous system by simultaneously stimulating the release and blocking the reuptake of dopamine and norepi- Like cocaine, methamphetamine exerts multiple effects on the cardiovascular system, all of which may pre- The acute effects of methamphetamine are euphoria, tachycardia, hypertension, and arrhythmias. MI may result from coronary spasm or plaque rupture in the presence of enhanced platelet aggregation. Long-term use of methamphetamine has been associated with myocardi- tis, necrotizing vasculitis, pulmonary hypertension, and car- Because methamphetamine and cocaine have similar pathophysiological effects, treatment of patients with ACS associated with methamphetamine and cocaine use should theoretically be similar. 