From the Guidelines
Beta blockers are still recommended post-myocardial infarction (MI) according to current guidelines, particularly in patients with reduced systolic left ventricular function (LVEF < 40%) or those without contraindications such as acute heart failure, haemodynamic instability, or higher degree AV block. The most recent and highest quality study, published in 2018 in the European Heart Journal 1, supports the use of beta blockers in post-MI patients, citing a significant mortality reduction associated with beta-blocker prescription at discharge.
Key Considerations
- Beta blockers should be initiated within the first 24 hours in patients with acute MI who do not have contraindications such as cardiogenic shock, severe bradycardia, high-degree heart block, or active bronchospasm.
- Common beta blockers used post-MI include metoprolol, carvedilol, and bisoprolol, which have been shown to reduce the risk of death in patients with reduced LVEF.
- Dose titration should be done gradually over weeks, monitoring for bradycardia, hypotension, and worsening heart failure symptoms.
- The long-term benefit of beta blockers in patients with preserved ejection fraction is less well established, but they can be considered for at least 3 years post-MI.
Evidence Summary
The 2018 European Heart Journal study 1 provides the most recent and highest quality evidence, demonstrating a significant mortality reduction associated with beta-blocker prescription at discharge. Additionally, a systematic review of randomized controlled trials published in 2017 in Circulation 1 showed that beta blockers are effective in secondary prevention after MI, imparting a 23% reduction in the odds of death in long-term trials.
Clinical Implications
In clinical practice, beta blockers should be considered a standard part of post-MI management, particularly in patients with reduced LVEF or those without contraindications. The choice of beta blocker and dosing should be individualized based on patient characteristics and clinical response. Regular monitoring and titration of beta blockers are essential to optimize their benefits and minimize potential adverse effects.
From the FDA Drug Label
DOSAGE & ADMINISTRATION SECTION ... 2.2 Left Ventricular Dysfunction Following Myocardial Infarction DOSAGE MUST BE INDIVIDUALIZED AND MONITORED DURING UP-TITRATION. Treatment with Carvedilol Tablet may be started as an inpatient or outpatient and should be started after the patient is hemodynamically stable and fluid retention has been minimized.
Beta blockers are still indicated post myocardial infarction (MI), as evidenced by the dosage and administration guidelines for carvedilol in patients with left ventricular dysfunction following MI 2.
- The dosage must be individualized and monitored during up-titration.
- Treatment may be started after the patient is hemodynamically stable and fluid retention has been minimized.