From the FDA Drug Label
The VALsartan In Acute myocardial iNfarcTion trial (VALIANT) was a randomized, controlled, multinational, double-blind study in 14,703 patients with acute myocardial infarction and either heart failure (signs, symptoms or radiological evidence) or left ventricular systolic dysfunction (ejection fraction ≤40% by radionuclide ventriculography or ≤35% by echocardiography or ventricular contrast angiography). Patients were randomized within 12 hours to 10 days after the onset of myocardial infarction symptoms to one of three treatment groups: valsartan (titrated from 20 or 40 mg twice daily to the highest tolerated dose up to a maximum of 160 mg twice daily), the ACE inhibitor, captopril (titrated from 6.25 mg three times daily to the highest tolerated dose up to a maximum of 50 mg three times daily), or the combination of valsartan plus captopril. The primary endpoint was time to all-cause mortality Secondary endpoints included (1) time to cardiovascular (CV) mortality, and (2) time to the first event of cardiovascular mortality, reinfarction, or hospitalization for heart failure.
The best ACE inhibitor and beta blocker combo in a patient with heart rate in the mid-60s after a recent heart attack is not explicitly stated in the provided drug labels.
- However, the VALIANT trial 1 compared the effects of valsartan, captopril, and the combination of valsartan plus captopril on patients with acute myocardial infarction.
- The trial found that there was no difference in overall mortality among the three treatment groups, and no evidence that combining captopril and valsartan was of value.
- Lisinopril 2 has been shown to be effective in reducing mortality and improving outcomes in patients with heart failure and acute myocardial infarction.
- Beta blockers are commonly used in combination with ACE inhibitors to reduce mortality and improve outcomes in patients with heart failure and acute myocardial infarction.
- However, the specific combination of ACE inhibitor and beta blocker that is best for a patient with heart rate in the mid-60s after a recent heart attack is not explicitly stated in the provided drug labels.
From the Research
For a patient with a heart rate in the mid-60s after a recent heart attack, a combination of lisinopril (an ACE inhibitor) and metoprolol succinate (a beta blocker) would be an appropriate choice, as this combination has been shown to provide complementary cardioprotective effects and reduce mortality 3. Start with lisinopril 2.5-5 mg daily, gradually titrating up to 10-20 mg daily as tolerated. For metoprolol succinate, begin with 12.5-25 mg daily and slowly increase to a target dose of 200 mg daily as tolerated, while carefully monitoring heart rate. This combination provides complementary cardioprotective effects: lisinopril reduces afterload and prevents adverse cardiac remodeling, while metoprolol decreases myocardial oxygen demand and arrhythmia risk. The relatively low starting heart rate requires cautious beta blocker initiation with close monitoring for bradycardia. Regular assessment of blood pressure, heart rate, renal function, and potassium levels is essential. If the patient develops symptomatic bradycardia, consider reducing the beta blocker dose rather than discontinuing it completely, as both medications offer significant mortality benefits post-myocardial infarction. Some studies suggest that angiotensin II receptor blockers (ARBs) may be an alternative to ACEIs in patients without heart failure after acute myocardial infarction, but the most recent and highest quality study 4 found no significant difference in all-cause death between ARBs and ACEIs in this population. Therefore, based on the available evidence, the combination of lisinopril and metoprolol succinate remains the preferred choice. It is also important to note that the use of beta blockers and ACEIs has been associated with improved outcomes in patients with myocardial infarction, including reduced mortality and morbidity 5, 3. In terms of specific dosing, the study by 5 found that higher doses of ACEIs were associated with improved outcomes, while the study by 3 found that the combination of beta blockers and ACEIs was associated with reduced mortality. Overall, the combination of lisinopril and metoprolol succinate is a reasonable choice for a patient with a heart rate in the mid-60s after a recent heart attack, and should be titrated to the maximum tolerated dose to maximize cardioprotective effects.