Know the Latest About Beta-Blockers After a Heart Attack

Recent evidence will reignite debate about the role of beta-blockers after a heart attack...in patients withOUT heart failure.

Many of us were taught that all post-MI patients should get a beta-blocker as part of the usual “cocktail”...to reduce recurrent CV events.

But this is based on evidence from the 1980s...before routine use of stents, high-intensity statins, dual antiplatelet therapy, etc.

And evidence over the past decade is mixed on the benefit of beta-blockers after an MI with a preserved ejection fraction of 50% or higher.

That’s why recent guidelines suggest beta-blockers for just 1 year in these patients...down from the 3-year recommendation of prior guidance.

Now, a new study suggests that beta-blockers do NOT benefit patients with a preserved ejection fraction who got a stent or had bypass surgery after a heart attack.

Educate that these data suggest taking bisoprolol or metoprolol succinate for about 3.5 years doesn’t reduce the risk of death, heart attack, or hospitalization for heart failure.

Point out limitations of this evidence...it’s an open-label study, and about 14% of patients not randomized to a beta-blocker still took one.

Expect evidence in the coming years to fill gaps...and possibly change guidelines down the road.

Continue to recommend an evidence-based beta-blocker (bisoprolol or carvedilol) indefinitely for post-MI patients WITH heart failure and an ejection fraction less than 50%.

For now, also anticipate seeing most other heart attack patients still discharged on a beta-blocker. In this case, recommend limiting it to 1 year or less...unless there’s another indication (angina, etc).

But don’t be surprised if prescribers have a lower threshold for stopping beta-blockers in these cases...especially if patients complain about bothersome side effects (fatigue, erectile dysfunction, etc).

Continue to advise stopping beta-blockers for more serious side effects, such as shortness of breath, slow heart rate, or light-headedness.

Warn patients not to stop their beta-blocker suddenly...especially if they’re on higher doses. Suggest tapering the beta-blocker off over 1 to 3 weeks...to possibly decrease the risk of angina.

See our resources, Comparison of Oral Beta-Blockersfor dosing guidance...and Optimizing Care of Patients With Coronary Artery Disease, for a comprehensive guide to appropriate therapy.

Key References

  • Yndigegn T, Lindahl B, Mars K, et al. Beta-Blockers after Myocardial Infarction and Preserved Ejection Fraction. N Engl J Med. 2024 Apr 18;390(15):1372-1381.
  • Virani SS, Newby LK, Arnold SV, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2023 Aug 29;148(9):e9-e119.
Pharmacist's Letter Canada. June 2024, No. 400601



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