What are the recommendations for initiating and managing beta‑blocker therapy after percutaneous coronary intervention, including timing, target heart rate and blood pressure, dosing, duration, and adjustments for elderly, low‑weight, or renally impaired patients and contraindications?

Beta-Blocker Therapy After PCI

Oral beta-blockers should be initiated within the first 24 hours after PCI in all patients without contraindications, with target heart rate 50-70 bpm and systolic blood pressure >100 mmHg, and continued indefinitely—especially in those with reduced ejection fraction (<40%), heart failure, or anterior MI. 1, 2

Initiation and Timing

• Start oral beta-blockers within 24 hours of PCI in hemodynamically stable patients (systolic BP >100-120 mmHg, heart rate >50-60 bpm, no acute heart failure). 1, 2

• Intravenous beta-blockers may be considered at presentation in patients undergoing primary PCI who have no contraindications, no signs of acute heart failure, and systolic BP >120 mmHg—particularly for ongoing ischemia, hypertension, or tachycardia. 1

• Avoid intravenous beta-blockers in patients with hypotension, acute heart failure, AV block, severe bradycardia, or high-dose initiation without titration. 1

• Ideally begin therapy 2-30 days before elective PCI when feasible, though this applies more to non-cardiac surgery settings. 1

Agent Selection and Dosing

• Preferred agents include metoprolol succinate, carvedilol, or bisoprolol—these have proven mortality benefit in patients with reduced LVEF. 2, 3

• For acute initiation, atenolol or bisoprolol may be considered as first-choice agents. 1

• Start at low doses and titrate gradually based on hemodynamic tolerance:

  • Metoprolol: begin 25-50 mg twice daily, titrate to target 200 mg daily 3, 4
  • Carvedilol: begin 3.125-6.25 mg twice daily, titrate to 25 mg twice daily 5, 3
  • Bisoprolol: begin 1.25-2.5 mg daily, titrate to 10 mg daily 1, 2

• Avoid high-dose initiation without titration, as this increases risk of cardiogenic shock and mortality. 1

Target Parameters

• Target resting heart rate: 50-70 bpm (some guidelines specify 60-70 bpm). 1, 2, 4

• Maintain systolic blood pressure >100 mmHg (mean arterial pressure >55 mmHg). 1

• Titrate dose every 1-2 weeks until target heart rate achieved or limiting side effects occur. 2, 5, 3

• Monitor heart rate and blood pressure closely during titration, checking at 1-2 weeks after each dose adjustment. 5, 3

Duration of Therapy

• Continue indefinitely in all patients with heart failure or LVEF <40%. 1, 2, 3

• For patients with preserved LVEF (≥40-50%) after complete revascularization, continue for at least 3 years, though recent evidence questions benefit in this specific subgroup. 1, 2, 6, 7

• Do not discontinue beta-blockers even if LVEF normalizes, as relapse and decline are common after withdrawal. 3

• For patients with positive stress testing pre-operatively, long-term beta-blocker therapy should be used for several months. 1

Special Populations

Elderly Patients

• Use lower starting doses and slower titration schedules. 1
• Patients >70 years have increased risk of cardiogenic shock with aggressive dosing. 1
• Monitor closely for hypotension, bradycardia, and falls. 1, 5

Low-Weight Patients

• Reduce initial doses proportionally (e.g., start metoprolol at 12.5-25 mg twice daily). 1
• Titrate more cautiously based on hemodynamic response. 2, 5

Renal Impairment

• Hydrophilic beta-blockers (atenolol, nadolol) require dose adjustment for creatinine clearance <30 mL/min. 1
• Lipophilic agents (metoprolol, carvedilol, bisoprolol) do not require renal dose adjustment but monitor for accumulation of active metabolites. 2, 3
• Check renal function and electrolytes at baseline, 24-48 hours after initiation, and before discharge. 3

Absolute Contraindications

• Cardiogenic shock or acute decompensated heart failure with signs of low output. 1

• Severe bradycardia (heart rate <50 bpm) or symptomatic bradycardia. 1

• High-degree AV block (second- or third-degree) without a pacemaker. 1, 2

• Severe hypotension (systolic BP <90 mmHg or >30 mmHg below baseline). 1

• Severe reactive airways disease or acute asthma exacerbation. 1

• Active peripheral vascular disease with rest ischemia. 2

Relative Contraindications and Cautions

• Mild-to-moderate COPD: cardioselective beta-blockers (metoprolol, bisoprolol) can be used with caution and close monitoring. 2, 3

• Intermittent claudication: beta-blockers have not been shown to worsen symptoms and are not contraindicated. 1

• Decompensated heart failure: adjust therapy to clinical condition; defer non-cardiac procedures until stable on optimal medical therapy. 1, 3

Monitoring and Adjustments

• Vital signs every 4-8 hours during acute hospitalization. 3

• Continuous telemetry during acute phase to detect arrhythmias or heart block. 3

• Renal function and electrolytes at baseline, 24-48 hours after initiation, and before discharge. 3

• If hypotension develops (SBP <90 mmHg), temporarily reduce dose. 5, 3

• If bradycardia occurs (HR <55 bpm), reduce dose. 5, 3

• For post-operative tachycardia, first treat underlying causes (hypovolemia, pain, blood loss, infection) rather than simply increasing beta-blocker dose. 1

Common Pitfalls

• Do not abruptly discontinue beta-blockers in patients on chronic therapy, as this increases risk of rebound ischemia and arrhythmias. 1, 2

• Do not use immediate-release dihydropyridine calcium channel blockers as substitutes for beta-blockers in acute settings. 1

• Do not give intravenous beta-blockers to patients with signs of heart failure, low-output state, or increased risk of cardiogenic shock. 1

• Do not target heart rate <50 bpm, as excessive bradycardia may be harmful. 1, 2, 4

• Do not use beta-blockers as monotherapy for rate control in atrial fibrillation post-PCI; consider combination with digoxin if inadequate control. 5

Integration with Other Therapies

• Continue beta-blockers alongside ACE inhibitors/ARBs, high-intensity statins, mineralocorticoid receptor antagonists, and antiplatelet therapy. 1, 3

• Add proton pump inhibitor when combining beta-blockers with dual antiplatelet therapy to reduce GI bleeding risk. 3

• Coordinate with cardiac rehabilitation enrollment, as beta-blockers improve exercise tolerance and outcomes. 3