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Beta Blockers After Myocardial Infarction

 

1. Of all the therapies currently available for the prevention of sudden cardiac death, none is more established or more effective than beta-blockers. Controlled trials have demonstrated from 26% to 43% reduction in overall mortality at 25 months post-MI for patients given chronic beta-blocker therapy after myocardial infarction compared to patient's given placebo.

2. Beta-blockers are generally well tolerated; however tiredness (5%), bronchospasm (4%), cold extremities (2%), and diarrhea (2%) have been reported significantly more often than control patients during clinical trials (the numbers in parenthesis reflect the difference between propranolol and control group reports of these symptoms).

3. For maximum effectiveness, a beta-blocker should be started within two weeks of an acute MI.

It is important to maintain beta blockade throughout the dosing interval.

4. Beta-blockers that have shown significant reductions in cardiovascular mortality when started within two weeks of an MI include: propranolol, timolol, metoprolol, atenolol, and acebutolol.

5. Serious complications of beta-blockers are relatively rare.

Although beta-blockers have traditionally been avoided in congestive heart failure, more recent data has demonstrated that most patients with chronic CHF actually demonstrate improved cardiac function on beta-blockers.

Obstructive airways disease is a relative contraindication to the use of beta-blockers. These patients may benefit from the use of low dose cardioselective (B1) beta-blockers.

Beta-blockers have been reported to have an adverse effect on serum lipids. Non-selective beta-blockers tend to decrease HDL levels by about 10% and increase triglyceride levels by 25-30%. Cardioselective beta-blockers have a less pronounced effect. Even for patients who experienced the adverse effects on lipids, mortality after MI was reduced by 20% in a large controlled trial.

Patients with mild to moderate peripheral vascular disease can probably be given beta-blockers safely. Patients with severe PVD (pain at rest, ischemic ulcers) should probably not receive beta-blockers.

 

References
Goldstein, S. Beta-Blockers in Hypertensive and Coronary Artery Disease (Review). Archives of Internal Med. 1996;156:1267-1276.
Soumerai, et. Al., Adverse Outcomes of Under-use of Beta-Blocker in Elderly Survivors of Acute Myocardial Infarction. JAMA. 1997;277:115-121.
Kendall, M.J., et. al., Beta-Blockers and Sudden Cardiac Death. Ann Intern Med. 1995;123:358-367.
Beta-Blocker Heart Attack Trial Research Group. A Randomized Trial of Propranolol in Patients with Acute Myocardial Infarction, I: mortality results. JAMA. 1982;247:1707-1714.
Norwegian Multi center Study Group. Timolol Induced Reduction in Mortality and Reinfarction in Patients Surviving Acute Myocardial Infarction. N Engl J Med. 1981;304:801-807.
Bristow, et. al., Dose-Response of Chronic Beta-Blocker Treatment in Heart Failure From Either Idiopathic Dilated or Ischemic Cardiomyopathy. Circulation. 1994;89:1632-1642.
Packer, M., Bristow, et. al, The Effect of Carvedilol On Morbidity and Mortality in Patients With Chronic Heart Failure. N Engl J Med. 1996;334:1349-1355.
Waagstein, F., Bristow, et al, Beneficial Effects of Metoprolol in Idiopathic dilated cardiomyopathy. Lancet. 1993;342:1441-14446.