Is there evidence for morbidity and mortality benefit with daily beta-blocker use in patients with ischemic heart disease (IHD) who underwent drug-eluting stent (DES) placement for ST-elevation myocardial infarction (STEMI) less than a year ago, without pre-existing hypertension or diabetes, and what about the use of Angiotensin-Converting Enzyme inhibitors (ACEIs) or Angiotensin Receptor Blockers (ARBs)?

Beta-Blockers and ACE Inhibitors/ARBs in Post-STEMI Patients with DES Placement

Beta-blockers should be used indefinitely in all post-STEMI patients who underwent DES placement within the past year, even without pre-existing hypertension or diabetes, as they reduce mortality and reinfarction by 20-25%. 1

Beta-Blockers After STEMI

• Beta-blockers provide significant mortality and morbidity benefits in post-STEMI patients, with evidence from multiple trials and meta-analyses demonstrating a 20-25% reduction in reinfarction and death 1
• The benefit persists even when ACE inhibitors are co-administered, as shown in a meta-analysis of 82 randomized trials 1
• For patients without heart failure or hypertension who had uncomplicated MI, the AHA/ACCF secondary prevention guidelines recommend at least a 3-year treatment course 1
• The strongest evidence for beta-blocker benefit is in patients with MI complicated by heart failure, left ventricular dysfunction, or ventricular arrhythmias 1

Important Considerations:

• While most beta-blocker trials were conducted in the pre-reperfusion era, the evidence remains strong for their use in the current DES era 1
• Contraindications to beta-blockers should be assessed, including severe bradycardia, hypotension, or severe reactive airway disease 1
• If beta-blockers are contraindicated, calcium channel blockers like verapamil or diltiazem may be considered as alternatives, though they have weaker evidence 1

ACE Inhibitors and ARBs After STEMI

• ACE inhibitors should be administered to all STEMI patients with anterior location, heart failure, or ejection fraction ≤0.40 (Class I recommendation, Level A evidence) 1
• ACE inhibitors are reasonable for all STEMI patients without contraindications (Class IIa recommendation, Level A evidence) 1
• For patients without specific indications (anterior MI, EF ≤0.40, HF), the role of routine long-term ACE inhibitor therapy is less certain in low-risk patients who have been revascularized and treated with aggressive lipid-lowering therapies 1
• ARBs should be given to STEMI patients who have indications for but are intolerant of ACE inhibitors (Class I recommendation, Level B evidence) 1

Comparative Effectiveness of ACE Inhibitors vs ARBs:

• Recent evidence suggests that the combination of beta-blockers with ACE inhibitors may be more beneficial than beta-blockers with ARBs in reducing major adverse cardiac events (MACE) in STEMI patients after successful PCI with DES 2
• In patients without heart failure, ACE inhibitors and ARBs appear to have similar efficacy in preventing the composite endpoint of cardiovascular death, MI, and stroke 3
• The VALIANT trial found valsartan to be non-inferior to captopril in acute myocardial infarction patients 1, 4

Clinical Decision Algorithm

1. For all post-STEMI patients with DES placement within the past year:

   • Start/continue beta-blocker therapy indefinitely unless contraindicated 1
   • Consider at least a 3-year course even in uncomplicated MI without hypertension or diabetes 1

2. For ACE inhibitor/ARB therapy:

   • Definite indications (use ACE inhibitor):

     • Anterior MI location
     • Heart failure
     • LVEF ≤40%
     • Diabetes mellitus 1

   • Without definite indications:

     • ACE inhibitors are still reasonable for all STEMI patients without contraindications 1
     • Consider ACE inhibitors preferentially over ARBs when possible 2
     • Use ARBs only if ACE inhibitors are not tolerated 1

3. Duration of therapy:

   • Beta-blockers: Indefinite use recommended, minimum 3 years for uncomplicated MI 1
   • ACE inhibitors/ARBs: Indefinite use for patients with definite indications; for others, benefits beyond 3 years less certain 1

Common Pitfalls and Caveats

• Failing to reassess contraindications to beta-blockers after the acute phase - patients initially contraindicated may become eligible later 1
• Discontinuing beta-blockers prematurely in patients without hypertension or diabetes, despite evidence supporting their continued use 1
• Using ARBs as first-line therapy instead of ACE inhibitors - recent evidence suggests ACE inhibitors may be preferable when combined with beta-blockers 2
• Overlooking the need for aldosterone antagonists in eligible patients (EF ≤40% with either symptomatic heart failure or diabetes) 1