From the Guidelines
Beta blockers are not recommended for long-term use in patients with Coronary Artery Disease (CAD) without a primary indication, such as myocardial infarction in the past year or left ventricular ejection fraction ≤50%. However, they can be used as first-line antianginal therapy, either as a calcium channel blocker or a beta blocker, in patients with CAD 1. The use of beta blockers in CAD management has been reassessed, and current guidelines suggest that they should not be used solely for the purpose of improving outcomes in patients with CAD without specific indications 1. Key points to consider when using beta blockers in CAD patients include:
- They can be used for antianginal therapy
- They should not be used long-term without a primary indication
- They are recommended for patients with prior myocardial infarction, left ventricular ejection fraction ≤50%, or another primary indication for beta-blocker therapy
- Treatment should be individualized and based on patient-specific factors, including comorbidities and potential side effects 1. It is essential to weigh the benefits and risks of beta blocker therapy in each patient and to consider alternative therapies, such as calcium channel blockers, when appropriate 1.
From the FDA Drug Label
In Patients Without a History of Cardiac Failure Continued depression of the myocardium with beta-blockers can, in some patients, precipitate cardiac failure At the first signs or symptoms of heart failure, discontinuation of bisoprolol fumarate should be considered. In some cases, beta-blocker therapy can be continued while heart failure is treated with other drugs Abrupt Cessation of Therapy Exacerbation of angina pectoris, and, in some instances, myocardial infarction or ventricular arrhythmia, has been observed in patients with coronary artery disease following abrupt cessation of therapy with beta-blockers.
The role of beta blockers in the management of Coronary Artery Disease (CAD) is to:
- Reduce the risk of myocardial infarction or ventricular arrhythmia by continued use
- Possibly precipitate cardiac failure in some patients without a history of cardiac failure
- Exacerbate angina pectoris if therapy is abruptly ceased Key considerations for beta blocker use in CAD include:
- Caution with use in patients with peripheral vascular disease or bronchospastic disease
- Tapering therapy over approximately one week to avoid withdrawal symptoms 2
From the Research
Role of Beta Blockers in Coronary Artery Disease Management
- Beta blockers are a crucial group of drugs used in the treatment of patients with cardiovascular disease, including coronary artery disease (CAD) 3.
- They are used to treat all forms of coronary disease, especially in acute myocardial infarction and acute coronary syndromes, resulting in increased survival and improved quality of life (QoL) for patients with CAD 3.
- The administration of beta blockers to patients with CAD has been shown to reduce vascular mortality in the acute myocardial infarction (MI) period, with medications such as atenolol and metoprolol demonstrating decreased mortality 4.
Benefits of Beta Blockers in CAD
- Beta blockers provide multiple benefits to patients with CAD, including reduction of myocardial oxygen demand, making them effective for the treatment of angina pectoris 4.
- They have been shown to reduce arrhythmic death or cardiac arrest in patients with CAD, as demonstrated in the Cardiac Arrhythmia Suppression Trial (CAST) 4.
- Beta blockers have also been found to improve overall survival in patients with CAD, particularly in those who have undergone myocardial infarction, as shown in the AVID and MUSTT trials 4.
Contemporary Use of Beta Blockers in CAD
- Recent studies have investigated the efficacy of beta blockers in contemporary clinical practice, with mixed results 5, 6.
- A 2020 umbrella review and meta-analytic assessment found that beta blockers reduced mortality in patients with heart failure, but their efficacy in CAD was less clear, with a lack of benefit in contemporary studies where ≥50% of patients received thrombolytics or intervention 5.
- However, another 2020 study found that beta blockers provided a differential survival benefit in patients with CAD undergoing contemporary post-percutaneous coronary intervention management, particularly in those with acute myocardial infarction 6.
Use of Beta Blockers in Specific Populations
- Beta blockers have been found to be beneficial in patients with CAD and co-morbidity of chronic obstructive pulmonary disease (COPD), with lower mortality rates in beta blocker users compared to non-users 7.
- The use of beta blockers in patients with CAD and COPD has been shown to be comparable to those without COPD, with similar mortality benefits 7.