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We prospectively evaluated the prevalence of cocaine use in emergency department patients with elevated diastolic blood pressure greater than 120 mm Hg.Urine was collected on adult patients with diastolic blood pressure greater than 120 mm Hg. The Institutional Review Board granted a waiver of informed consent based on complete deidentification of the data to prevent selection bias. Spontaneously voided urine specimens were analyzed for the presence of the benzoylecgonine.Of 107 eligible patients with a diastolic blood pressure equal to or greater than 120 mm Hg, 99 were tested. Of the 99, 13 (13%) tested positive, and of which, 6 (46%) presented with a request for medication refill. Five patients (39%) had cardiovascular and/or pulmonary complaints.Emergency department patients with hypertension who have recently used cocaine may be difficult to differentiate from those who have not. Consideration should be given to the potential for cocaine use when making treatment decisions in patients with hypertension.