What beta blocker is added post Non-ST-Elevation Myocardial Infarction (NSTEMI) with mild hypertension and left ventricular ejection fraction (LVEF) of 50%?

From the Guidelines

Beta blockers such as metoprolol, carvedilol, or bisoprolol should be initiated in patients post-NSTEMI with mild hypertension and left ventricular ejection fraction (LVEF) of 50%. The choice of beta blocker is crucial, and according to the 2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and non-ST-elevation myocardial infarction 1, it is advisable to use beta blockers without intrinsic sympathomimetic activity. In patients with MI complicated with systolic cardiomyopathy with or without heart failure, one of the three proven beta blockers should be used: carvedilol, sustained-release metoprolol succinate, or bisoprolol 1. Key considerations for the management of these patients include:

• Initiating beta blockers within 24 hours of presentation if there are no contraindications such as cardiogenic shock, severe bradycardia, high-degree heart block, or decompensated heart failure
• Monitoring blood pressure and heart rate regularly, aiming for a resting heart rate of 55-60 beats per minute and maintaining systolic blood pressure above 90 mmHg
• Titration of the beta blocker dose as tolerated to achieve optimal heart rate and blood pressure control
• Continuation of beta blockers indefinitely unless contraindications develop, as they reduce myocardial oxygen demand, prevent recurrent ischemia, and reduce mortality post-MI 1. The recommended starting dose for metoprolol tartrate is 25-50 mg twice daily, titrated as tolerated to a target of 200 mg daily; for carvedilol, start with 3.125-6.25 mg twice daily, titrating to 25 mg twice daily; and for bisoprolol, begin with 1.25-2.5 mg once daily, increasing to 10 mg daily. These medications have been shown to decrease the risk of ventricular arrhythmias and sudden cardiac death, and improve outcomes in patients post-NSTEMI 1.

From the FDA Drug Label

CLINICAL STUDIES SECTION 14.2 Left Ventricular Dysfunction Following Myocardial Infarction CAPRICORN was a double-blind study comparing Carvedilol Tablet and placebo in 1,959 patients with a recent myocardial infarction (within 21 days) and left ventricular ejection fraction of less than or equal to 40%, with (47%) or without symptoms of heart failure.

The beta blocker that can be added post Non-ST-Elevation Myocardial Infarction (NSTEMI) with mild hypertension and left ventricular ejection fraction (LVEF) of 50% is carvedilol 2.

• The patient's LVEF of 50% is higher than the LVEF of less than or equal to 40% in the CAPRICORN study, but carvedilol may still be considered.
• The study showed that carvedilol reduced all-cause mortality and fatal or non-fatal myocardial infarction in patients with left ventricular dysfunction following a myocardial infarction.
• However, the specific scenario of NSTEMI with mild hypertension and LVEF of 50% is not directly addressed in the study.
• Therefore, the decision to add carvedilol should be made with caution and consideration of the individual patient's clinical situation.

From the Research

Beta Blocker Selection Post NSTEMI

• The selection of a beta blocker post Non-ST-Elevation Myocardial Infarction (NSTEMI) depends on various factors, including left ventricular ejection fraction (LVEF) and the presence of hypertension.
• According to the study 3, metoprolol and carvedilol are two commonly used beta blockers, but no specific beta blocker is recommended for patients with NSTEMI.
• The study 3 found that patients with LVEF >40% had similar survival rates with metoprolol and carvedilol, while patients with LVEF ≤40% had better survival rates with carvedilol.

Considerations for Patients with Mild Hypertension and LVEF of 50%

• For patients with mild hypertension and LVEF of 50%, the choice of beta blocker may depend on individual patient characteristics and comorbidities.
• The study 4 suggests that nebivolol, a third-generation beta blocker, may be a suitable option for hypertensive patients with or without comorbidities due to its vasodilating properties and neutral metabolic effects.
• The study 5 found that nebivolol and carvedilol had similar effects on LVEF and clinical outcomes in hypertensive heart failure patients, but nebivolol may be a better option for patients with mild hypertension due to its favorable pharmacological profile.

Summary of Beta Blocker Options

• Metoprolol and carvedilol are two commonly used beta blockers post NSTEMI, but the choice of beta blocker may depend on individual patient characteristics and comorbidities.
• Nebivolol may be a suitable option for patients with mild hypertension and LVEF of 50% due to its vasodilating properties and neutral metabolic effects.
• Further studies are needed to determine the optimal beta blocker for patients with NSTEMI and mild hypertension, as the current evidence is limited 3, 6, 7, 4, 5.