Are Long-Term Beta Blockers Following MI in the Absence of Angina and HF Indicated in the PCI Era?

Oct 25, 2021   |  Manish Kumar, MD; Christina Al Malouf, MBBS, FACC; Craig J. Beavers, PharmD, FACC

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  • Beta blocker use after the initial acute myocardial infarction treatment phase in patients with no other clinical indication for its use (e.g., angina, heart failure, cardiac arrhythmias) was associated with no long-term cardiovascular benefit at 3 years follow up.

The use of beta blockers (BB) in acute coronary syndromes (ACS), angina, and heart failure (HF) with reduced ejection fraction (EF) are well-established. However, in the era of reperfusion with percutaneous coronary interventions (PCI), the long-term benefits of BB in coronary artery disease in patients without symptoms of angina or HF are unknown.

  1. BB inhibit catecholamine from binding to beta-1 and beta-2 receptors present in the myocardium, thus reducing heart rate, conduction speed, and contractility. Myocardial infarction (MI) causes high sympathetic activity which can be blunted by BB. This leads to reduced oxygen demand, which in turn, protects against cardiac arrhythmias and symptomatic relief from angina.1
  2. Immediate myocardial reperfusion following MI is also a strong inhibitor of sympathetic activity. Therefore, the widespread use of long-term BB following MI in completely revascularized patients without residual angina or left ventricle (LV) dysfunction is debated.
  3. Most of the data regarding long term benefits of BB stems from studies done in the pre-PCI era and before the widespread use of anti-platelets and statins and therefore extrapolating the results of those trials to current practice presents important limitations.2
  4. The use of BB in patients with non-ST-elevation MI (STEMI) with preserved EF is a class IIa recommendation by the 2014 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines; however, European Society of Cardiology (ESC) guidelines omit any recommendations and identifies this as a gap in evidence in need for further investigation.3,4
  5. 2014 AHA/ACC guidelines for non-STEMI also state that it is reasonable to continue BB therapy beyond 3 years in patients with normal LV function and without angina after ACS (IIa,B).3
  6. Routine long-term use of BB in patients after STEMI with preserved EF and no angina is a class Ib recommendation by the 2013 ACC/AHA guidelines and a Class IIa recommendation by ESC 2017 guidelines.5,6
  7. Holt et al. sought to investigate cardiovascular (CV) benefits associated with long term BB use in patients who are stable after MI with no residual angina or HF. They found that long-term BB treatment exceeding 3 months in patients optimally treated for MI with no HF or angina was not associated with reduction in CV death, recurrent MI, or a composite outcome of CV events.7
  8. Older adults have lower cardiac output, high peripheral vascular resistance, reduced renal blood flow and glomerular filtration rate, and low plasma renin activity compared to younger individuals. Because of these normal aging physiological changes, BB can exhibit more pronounced adverse effects in these patients and should be considered where applicable.8
  9. Therefore, in older adults who are completely revascularized and have no LV dysfunction or residual angina, long term BB therapy should be reassessed after 3 months since these drugs may cause adverse effects with no appreciable long-term benefits.
  10. We recommend an individualized approach for the use of BB in older adults who have stable optimally treated ACS in the absence of HF, angina, and no other clear indication for BB use.

Management of CV conditions in addition to co-existing geriatric syndromes in elderly patients is challenging and often leads to polypharmacy which can lead to prescribing error, drug related adverse effects, drug interactions and hospital readmissions. In patients who are optimally revascularized and do not have symptoms of angina or LV dysfunction, BB discontinuation can be considered to reduce pill burden and adverse effects and improve medication adherence.

References

  1. Katzung BG, Masters SB, Trevor AJ, eds. Basic and Clinical Pharmacology. New York: McGraw-Hill Medical; 2012:313–329.
  2. Bauer T, Gitt AK, Jünger C, et al. Guideline-recommended secondary prevention drug therapy after acute myocardial infarction: predictors and outcomes of nonadherence. Eur J Prev Cardiol Rehabil 2010;17:576–81.
  3. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;64:e139–e228.
  4. Collet JP, Thiele H, Barbato E, et al. 2020 ESC guidelines for the management of acute coronary syndrome in patients presenting without persistent ST-segment elevation. Eur Heart J 2021;42:1289–1367.
  5. O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;61:e78–e140.
  6. Ibanez B, James S, Agewall S, et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018;39:119–77.
  7. Holt A, Blanche P, Zareini B, et al. Effect of long-term beta-blocker treatment following myocardial infarction among stable, optimally treated patients without heart failure in the reperfusion era: a Danish, nationwide cohort study. Eur Heart J 2021;42: 907–14.
  8. Messerli FH. The age factor in hypertension. Hosp Pract (Off Ed) 1986;21:103-12.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Nonstatins, Novel Agents, Statins, Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine, Chronic Angina, Geriatric Cardiology

Keywords: Hydroxymethylglutaryl-CoA Reductase Inhibitors, Coronary Artery Disease, Percutaneous Coronary Intervention, Acute Coronary Syndrome, Myocardial Reperfusion, ST Elevation Myocardial Infarction, Heart Rate, Polypharmacy, American Heart Association, Patient Readmission, Glomerular Filtration Rate, Stroke Volume, Catecholamines, Heart Ventricles, Myocardial Infarction, Heart Failure, Arrhythmias, Cardiac, Myocardium, Aging, Renal Circulation, Vascular Resistance, Cardiology, Pharmaceutical Preparations, Drug Interactions, Medication Adherence, Plasma, Oxygen


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