Is a beta blocker (beta-adrenergic blocking agent) required after a myocardial infarction (MI) in patients who experience orthostatic hypotension while on it?

From the Guidelines

Beta blockers are not absolutely required after a myocardial infarction (MI) if you experience orthostatic hypotension while taking them, and the decision to continue or modify their use should be individualized based on the patient's overall cardiovascular risk and severity of orthostatic symptoms. If you develop symptoms like dizziness or lightheadedness when standing up while on a beta blocker, your healthcare provider may consider alternative medications or adjusted dosing 1. Beta blockers such as metoprolol, carvedilol, or bisoprolol are typically prescribed after an MI to reduce heart workload and prevent future cardiac events, but their benefits must be balanced against side effects. According to the 2020 standards of medical care in diabetes, beta blockers should be continued for at least 2 years after the event in patients with prior myocardial infarction 1. However, for patients with orthostatic symptoms, alternatives might include ACE inhibitors, ARBs, or calcium channel blockers, depending on your specific cardiac condition.

Some key points to consider when making this decision include:

• The patient's overall cardiovascular risk
• The severity of their orthostatic symptoms
• Other medical conditions they may have
• The potential benefits of beta blockers in reducing the risk of death and future cardiac events, as demonstrated in studies such as the 2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and non-ST-elevation myocardial infarction 1
• The potential for alternative medications or adjusted dosing to minimize side effects while still providing benefits.

Regular follow-up with your healthcare provider is essential to monitor your blood pressure, heart rate, and symptoms to ensure optimal management of your post-MI care. The most recent and highest quality study, which is the 2020 standards of medical care in diabetes 1, should be prioritized when making this decision.

From the FDA Drug Label

DOSAGE & ADMINISTRATION SECTION Carvedilol Tablet should be taken with food to slow the rate of absorption and reduce the incidence of orthostatic effects. A lower starting dose may be used (3.125 mg twice daily) and/or the rate of up-titration may be slowed if clinically indicated (e.g., due to low blood pressure or heart rate, or fluid retention). Patients should be maintained on lower doses if higher doses are not tolerated.

The use of a beta blocker after a myocardial infarction (MI) in patients who experience orthostatic hypotension while on it is not absolutely required, but can be continued with caution.

• The dose may need to be lowered or the rate of up-titration slowed to minimize orthostatic effects.
• Patients should be closely monitored for signs of orthostatic hypotension, and the dose adjusted as needed to balance the benefits and risks of beta blocker therapy 2.

From the Research

Beta Blocker Therapy after Myocardial Infarction

• The use of beta blockers after a myocardial infarction (MI) is a well-established practice, with studies showing a significant reduction in mortality and reinfarction rates 3, 4.
• However, the question of whether a beta blocker is required after an MI in patients who experience orthostatic hypotension while on it is more complex.
• Orthostatic hypotension is a potential side effect of beta blocker therapy, and its presence may necessitate a reevaluation of the treatment plan.

Considerations for Discontinuation

• Recent studies have suggested that long-term beta blocker therapy may not be necessary for all patients after an MI, particularly those with preserved left ventricular function 5, 6.
• The decision to discontinue beta blocker therapy should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.
• Patients who experience orthostatic hypotension while on beta blocker therapy may be considered for discontinuation or dose reduction, especially if they do not have other indications for beta blocker use.

Choice of Beta Blocker

• The choice of beta blocker may also be an important consideration, with some studies suggesting that certain beta blockers (such as carvedilol) may be more effective than others (such as metoprolol) in certain patient populations 7.
• However, the optimal choice of beta blocker for patients with orthostatic hypotension is not well established, and further research is needed to guide clinical decision-making.