Do you prescribe beta blockers to a patient with a normal heart post-percutaneous coronary intervention (PCI)?

From the Guidelines

Beta blockers are not routinely recommended for patients with normal heart function following percutaneous coronary intervention (PCI). For patients with preserved left ventricular function and no other indications for beta blockade, there is insufficient evidence to support their routine use post-PCI, as stated in the 2024 ESC guidelines for the management of chronic coronary syndromes 1. Beta blockers should be reserved for specific indications such as recent myocardial infarction, reduced left ventricular ejection fraction (<40%), heart failure, or for controlling symptoms of angina or arrhythmias.

Some key points to consider when deciding on beta blocker therapy include:

• The patient's left ventricular function: Beta blockers are recommended for patients with reduced left ventricular ejection fraction (<40%) or heart failure 1.
• The presence of other indications for beta blockade: Such as recent myocardial infarction, or for controlling symptoms of angina or arrhythmias.
• The potential side effects of beta blockers: Including fatigue, bradycardia, hypotension, and bronchospasm.

Common beta blockers used when indicated include metoprolol (25-100 mg twice daily), carvedilol (3.125-25 mg twice daily), or bisoprolol (2.5-10 mg daily). For most patients with normal cardiac function after uncomplicated PCI, standard therapy should focus on dual antiplatelet therapy, statins, lifestyle modifications, and regular follow-up rather than routine beta blocker therapy. The 2024 ESC guidelines provide the most recent and highest quality evidence for the management of chronic coronary syndromes, and should be consulted for specific recommendations on beta blocker use in this context 1.

From the FDA Drug Label

In a large (1,395 patients randomized), double-blind, placebo-controlled clinical study, metoprolol was shown to reduce 3-month mortality by 36% in patients with suspected or definite myocardial infarction Patients were randomized and treated as soon as possible after their arrival in the hospital, once their clinical condition had stabilized and their hemodynamic status had been carefully evaluated.

The answer to whether a patient with a normal heart should be put on beta blockers post PCI is not directly addressed in the provided drug label. The label discusses the use of metoprolol in patients with suspected or definite myocardial infarction, but does not provide information on its use in patients with normal hearts post PCI. Key points:

• The study focused on patients with suspected or definite myocardial infarction.
• The drug label does not provide direct information on the use of beta blockers in patients with normal hearts post PCI. 2

From the Research

Beta Blocker Use Post PCI

• The use of beta blockers in patients with normal heart function after percutaneous coronary intervention (PCI) is a topic of ongoing debate 3.
• A study published in 2021 found that beta blocker use was associated with reduced mortality in patients with left ventricular ejection fraction (LVEF) <35% and LVEF 35%-50%, but not in those with LVEF >50% 3.
• Another study published in 2013 found that beta blocker prescription at discharge was not associated with better cardiovascular outcomes in patients who underwent PCI after ST-elevation myocardial infarction (STEMI) 4.
• The 2021 study suggests that beta blocker use may be beneficial in patients with reduced ejection fraction, but not in those with preserved ejection fraction 3.

Patient Management Post PCI

• Patient management post PCI should follow three main principles: lifestyle modification and reduction of risk factors, implementation of secondary prevention therapies, and timely detection of restenosis 5.
• Secondary prevention therapies, including beta blockers, should be prescribed in a way that balances ischemic and bleeding risk 5.
• A study published in 2010 emphasizes the importance of careful triage and management of bleeding and arrhythmias after PCI 6.

Beta Blocker Compliance

• A study published in 2006 found that compliance with beta blockers, angiotensin-converting enzyme inhibitors, and statins after acute myocardial infarction was generally good, but dosages were often lower than those used in clinical trials 7.
• The study suggests that increased age and female sex were associated with improved compliance, and that patients who did not start treatment shortly after discharge had a low probability of starting treatment later 7.