From the Guidelines
Beta blockers and ACE inhibitors/ARBs should not be automatically started for all NSTEMI patients regardless of blood pressure, but rather initiated based on individual patient characteristics and clinical status. For beta blockers, they should be initiated within the first 24 hours in patients without contraindications such as acute heart failure, evidence of low-output state, risk for cardiogenic shock, PR interval >0.24 seconds, second or third-degree heart block, active asthma, or reactive airway disease, as recommended by the 2014 AHA/ACC guideline 1. Common options include metoprolol tartrate 25-50 mg orally every 6-12 hours or metoprolol succinate 25-200 mg daily. For ACE inhibitors/ARBs, they should be started within the first 24 hours in NSTEMI patients with left ventricular ejection fraction ≤40%, heart failure, hypertension, or diabetes, but should be avoided in patients with hypotension (systolic BP <100 mmHg), acute kidney injury, or hyperkalemia, as supported by the 2015 ESC guidelines 1. Typical starting doses include lisinopril 2.5-5 mg daily, ramipril 2.5 mg daily, or valsartan 40 mg daily. Blood pressure should be monitored closely after initiation, with a target systolic BP of 130-140 mmHg, as recommended by the 2015 ESC guidelines 1. These medications improve outcomes by reducing myocardial oxygen demand, preventing adverse remodeling, and decreasing mortality in appropriate patients, but their use must be individualized based on the patient's clinical status. Key considerations include:
- Initiating beta blockers and ACE inhibitors/ARBs in patients without contraindications
- Monitoring blood pressure and adjusting medication doses as needed
- Individualizing treatment based on patient characteristics and clinical status
- Following guideline-recommended target blood pressure values. The most recent and highest quality study, the 2015 ESC guidelines 1, provides the basis for these recommendations, emphasizing the importance of individualized treatment and careful consideration of patient characteristics and clinical status.
From the Research
Beta Blockers and ACE/ARBs in NSTEMI Patients
- The use of beta blockers in NSTEMI patients has been associated with improved outcomes, including lower hospital mortality and lower mortality at 6 months postdischarge 2, 3.
- Early beta-blocker therapy is recommended for patients with NSTEMI, unless contraindicated, as it has been shown to reduce the risk of in-hospital mortality and improve clinical outcomes 3.
- The combination of beta blockers with ACE inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) has been studied in patients with NSTEMI, with some evidence suggesting that ACEIs may be more beneficial than ARBs in reducing major adverse cardiac events (MACE) and repeat revascularization 4, 5.
- However, the decision to start beta blockers and ACE/ARBs in NSTEMI patients should be individualized, taking into account the patient's blood pressure, heart rate, and other clinical factors, as well as the presence of any contraindications to these medications 6.
Considerations for Blood Pressure
- While the studies do not provide explicit guidance on starting beta blockers and ACE/ARBs in NSTEMI patients regardless of blood pressure, they do suggest that these medications can be beneficial in patients with NSTEMI, even in the absence of hypertension 2, 3.
- However, caution is advised when initiating these medications in patients with low blood pressure or other hemodynamic instability, as they can exacerbate these conditions 6.
Clinical Implications
- The available evidence supports the use of beta blockers and ACE/ARBs in patients with NSTEMI, unless contraindicated, as part of a comprehensive treatment strategy to reduce morbidity and mortality 2, 3, 4, 5.
- Clinicians should carefully consider the individual patient's clinical profile, including blood pressure and other factors, when deciding whether to initiate these medications 6.