Routine beta-blocker therapy after acute coronary syndromes: The end of an era?
Nicolas Johner1, Baris Gencer1,2,3, Marco Roffi1
1Cardiology Division, Geneva University Hospitals, Geneva, Switzerland.
Insights
Beta-blocker therapy is no longer routinely recommended after acute coronary syndromes (ACS) for patients with preserved left ventricular (LV) systolic function. Recent trials show no benefit in this population, challenging long-standing practice.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- Beta-blocker therapy historically reduced mortality post-acute coronary syndromes (ACS).
- Potential benefits included anti-arrhythmic effects and improved left ventricular (LV) remodeling.
- Contemporary treatments like reperfusion therapy have altered the risk-benefit profile of beta-blockers.
Purpose of the Study:
- To review contemporary evidence on beta-blocker use after ACS.
- To evaluate the role of beta-blockers in patients with preserved LV ejection fraction (LVEF).
Main Methods:
- Narrative review of PubMed-searched literature.
- Analysis of randomized controlled trials and observational studies.
Main Results:
- The REDUCE-AMI trial found no benefit of beta-blockers post-myocardial infarction with preserved LVEF.
- Benefits in patients with reduced LVEF remain clear.
- Observational data suggests potential benefit loss beyond 1-12 months in patients with LVEF >40%.
Conclusions:
- Routine beta-blocker prescription should be abandoned in post-ACS patients with preserved LV systolic function.
- Further research is needed for patients with mildly reduced LVEF (41%-49%).
Background:
Beta-blocker therapy, a treatment burdened by side effects including fatigue, erectile dysfunction and depression, was shown to reduce mortality and cardiovascular events after acute coronary syndromes (ACS) in the pre-coronary reperfusion era. Potential mechanisms include protection from ventricular arrhythmias, increased ischaemia threshold and prevention of left ventricular (LV) adverse remodelling. With the advent of early mechanical reperfusion and contemporary pharmacologic secondary prevention, the benefit of beta-blockers after ACS in the absence of LV dysfunction has been challenged.
Methods:
The present narrative review discusses the contemporary evidence based on searching the PubMed database and references in identified articles.
Results:
Recently, the REDUCE-AMI trial-the first adequately powered randomized trial in the reperfusion era to test beta-blocker therapy after myocardial infarction with preserved left ventricular ejection fraction (LVEF)-showed no benefit on the composite of all-cause death or myocardial infarction over a median 3.5-year follow-up. While the benefit of beta-blockers in patients with reduced LVEF remains undisputed, their value in post-ACS patients with mildly reduced systolic function (LVEF 41%-49%) has not been studied in contemporary randomized trials; in this setting, observational studies have suggested a reduction in cardiovascular events with these agents. The adequate duration of beta-blocker therapy remains unknown, but observational data suggests that any mortality benefit may be lost beyond 1-12 months after ACS in patients with LVEF >40%.
Conclusion:
We believe that there is sufficient evidence to abandon routine beta-blocker prescription in post-ACS patients with preserved LV systolic function.
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