Reconsider Beta-Blockers for Some Patients Post-MI

Recent evidence will reignite debate about the role of beta-blockers patients withOUT heart failure.

Many of us were taught to give a beta-blocker to all post-MI patients as part of the usual “cocktail” reduce recurrent CV events.

But this is based on evidence from the 1980s...before routine use of stents, high-intensity statins, dual antiplatelet therapy, etc.

And evidence over the past decade is mixed on the benefit of beta-blockers after an MI with a preserved ejection fraction of 50% or higher.

That’s why recent guidelines suggest beta-blockers for just 1 year in these patients...down from the 3-year recommendation of prior guidance.

Now, a new study suggests that beta-blockers do NOT benefit patients with a preserved ejection fraction who’ve undergone revascularization after an MI.

These data suggest that taking bisoprolol or metoprolol succinate for about 3.5 years doesn’t reduce the risk of death, MI, or heart failure hospitalization.

Keep limitations of this evidence in is an open-label study, and about 14% of the control group still took a beta-blocker.

Anticipate evidence in the coming years to fill gaps...and possibly change guidelines and quality measures down the road.

Continue to prescribe an evidence-based beta-blocker (bisoprolol, carvedilol, metoprolol succinate) indefinitely for post-MI patients WITH heart failure and an ejection fraction less than 50%.

For now, also expect most other post-MI patients to be discharged on a beta-blocker. In this case, limit it to 1 year or less...unless there’s another indication (angina, arrhythmias, etc).

Feel comfortable with a lower threshold for stopping beta-blockers earlier if these patients complain about bothersome side effects (fatigue, erectile dysfunction, etc).

And continue to stop beta-blockers for more serious side effects, such as symptomatic bradycardia or hypotension.

Warn patients not to stop their beta-blocker suddenly...especially if they’re on higher doses. Taper the beta-blocker off over 1 to 3 possibly decrease the risk of angina.

See our resources, Comparison of Oral Beta-Blockersfor dosing guidance...and Optimizing Care of Patients With Coronary Artery Disease, for a comprehensive guide to appropriate therapy.

Key References

  • Yndigegn T, Lindahl B, Mars K, et al. Beta-Blockers after Myocardial Infarction and Preserved Ejection Fraction. N Engl J Med. 2024 Apr 18;390(15):1372-1381.
  • Virani SS, Newby LK, Arnold SV, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2023 Aug 29;148(9):e9-e119.
Prescriber Insights. June 2024, No. 400601

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