THE ROLE OF BETA-BLOCKERS IN THE

MANAGEMENT AFTER MYOCARDIAL

INFARCTION
Dr. Nani Hersunarti, SpJP(K)

Department of Cardiology and Vascular Medicine

Faculty of Medicine Universitas Indonesia
National Cardiovascular Center Harapan Kita
 BETA-BLOCKERS REPRESENT 2 OF 7
RX STEPS THAT SHOULD BE PROVIDED IN
ALL ACUTE MYOCARDIAL INFARCTIONS

Aspirin - Early Administration

Aspirin at Discharge
Beta-Blocker - Early Administration
Beta-Blocker at Discharge
ACE or ARB at Discharge if LV Systolic Dysfunction
Statin Early Administration
Timely Initiation of Reperfusion
Life-Style Modification
CARDIAC EFFECTS OF BETA-ADRENERGIC
BLOCKING DRUGS

Opie LH, Gersh BJ, et al. Drugs for the Heart. 7 th Ed, 2009
EFFECTS OF ETA-BLOCKADE ON ISCHEMIC HEART

Opie LH, Gersh BJ, et al. Drugs for the Heart. 7 th Ed, 2009
 CLASSIFICATION OF -BLOCKERS

ISA:Intrinsic Sympathomimetic Activity Adapted from: European Heart Journal (2004) 25, 1341-1362
Intrinsic
Intrinsic Sympathomimetic
Sympathomimetic Activity
Activity (ISA)
(ISA) or
or
Partial
Partial Agonist
Agonist Effect
Effect

The most obvious pharmacological aspect

of Beta-blockers with ISA is that they
produce less of a decrease in resting heart
rate than agents without ISA
SECONDARY PREVENTION OF MYOCARDIAL INFARCTION WITH
DIFFERENT TYPES OF ETA-BLOCKERS
Reduction of
mortality 1-selective without ISA
%
Non-selective without ISA

-30
1-selective with ISA

Non-selective with ISA

-20

-10

-blockers without ISA -blockers with ISA

Adapted form:Progress in Cardiovascular Diseases. 27(5):335-71, 1985 Mar-Apr

 WHY IS DELIVERING RELIABLE AND
EVIDENCE-BASED AMI CARE IMPORTANT?
This is a frequent and important clinical problem.
Every year, an estimated 1.1 million people in the United
States are diagnosed with an acute myocardial infarction,
and approximately 350,000 of these patients die during the
acute phase.

Lives can be saved by good medical care.

Medicare estimates that by implementing all seven evidence-
based care components, acute myocardial infarction
inpatient mortality will be reduced by as much as 40%.

ACCF/AHA Guideline for The Management of ST-Elevation Myocardial Infarction, 2013

McGlynn et al. The Quality of Healthcare Delivery To Adults in the United States. N Engl J Med 2003
 NEED FOR THIS PRESENTATION
MEDICARE QUALITY DATA DEMONSTRATED

Despite knowledge since the early 1980s of the benefits of

beta-adrenergic blockers, after acute myocardial infarction,
only 45% received beta-blockers.

Subsequent studies have shown improvement, but there

is still a big treatment gap.

McGlynn et al. The Quality of Healthcare Delivery To Adults in the United States. N Engl J Med 2003
 LETS REVIEW THE DATA THAT SUPPORTS
THE BENEFIT OF BETA-BLOCKER THERAPY
IN AMI

Pre-Thrombolytic Era

Reperfusion Era (Lytics, PCI, and CABG)

PRE-TROMBOLYTIC ERA
BETA BLOCKER HEART ATTACK TRIAL (BHAT) 1986
3,837 patients randomized
Propranolol or placebo and followed for 25 months

Propranolol significantly reduced:

total mortality
cardiovascular mortality
sudden death
nonfatal infarction

A randomized trial of propanolol in patients with acute myocardial infarction. JAMA 1982;247
 CONCLUSION OF PRE-TROMBOLYTIC ERA

Multiple studies for over 20 years have demonstrated:

Beta-blockers in patients Pre-Thrombolytic Era have a
mortality benefit ranging between 10 and 15%
REPERFUSION ERA
 UNDER-USAGE OF BETA-BLOCKERS AFTER
MYOCARDIAL INFARCTION

Use of medications post MI

70
60
50
40
30
20
10
0
-blockers Ca-Channel blockers ACE-Inhibitors ASA

Ellerbeck et al. JAMA 1995; 273: 1509

 BETA BLOCKADE AFTER MYOCARDIAL
INFARCTION - 1999
Meta analysis of 31 long-term trials performed during the
reperfusion era on almost 25,000 patients

10.1% reduction in overall mortality

Freemantle et al. Beta Blockade after Myocardial Infarction: Systematic Review and Meta Regression Analysis. BMJ
1999 318:1730
 INTERNATIONAL STUDY OF INFARCT SURVIVAL
ISIS-1
16,027 patients randomized
Atenolol or placebo followed for 1 year

Atenolol significantly reduced :

Total mortality
Cardiovascular mortality

A randomized trial of intravenous atenolol among 16,027 cases of suspected acute myocardial
infarction : ISIS-1. Lancet 1986;2
 CAPRICORN-2001
1.959 patients randomized
Carvedilol or placebo followed for 1 year
Demonstrate the benefit carvedilol following acute MI in patients
with LV dysfunction
Carvedilol significantly reduced :
All-cause mortality
All-cause mortality or hospital admission secondary to
cardiovascular cause
Sudden death
Hospital admission for heart failure
Non-fatal MI

Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction
the CAPRICORN randomized trial. Lancet 2001 May 5
 CONCLUSION OF TROMBOLYTIC ERA
Large trials have demonstrated that beta-blockers benefit all
these AMI patient groups
No reperfusion therapy
Thrombolytic therapy
Percutaneous coronary intervention
CABG
 CAUTION #1:
DOCUMENTATION
Failure to give a beta-blocker, with a good clinical reason,
and to then not appropriately document this, is often
analyzed and publicly interpreted as underuse, a gap in
care or poor medical care.

The further assumption is that these non- treated patients

often suffered a higher unnecessary rate of death and
complications.
 THE PRACTICE STANDARD FOR BETA BLOCKERS
MAKES TWO MEASUREMENTS AND REQUIRES TWO
CHART DOCUMENTATIONS :

Was it given in the first 24 hours?

Was the patient discharged on a BB?

 CAUTION #2:
DO NO HARM

What are clinical situations where a beta-blocker should not

be given and could hurt the patient ?

CONTRAINDICATIONS TO BETA-BLOCKER USE DURING
ACUTE MYOCARDIAL INFARCTION

Sign of Heart Failure

Low output state
Increased risk of cardiogenic shock
Prolonged first-degree or high-grade AV block
Reactive airway disease

ACCF/AHA Guideline for The Management of ST-Elevation Myocardial Infarction, 2013

ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment
elevation, 2012
 COMMIT-CCS-2 TRIAL
2005

The data of the recently completed COMMIT Trial

reinforces that beta-blocker therapy should be withheld
if the patient is at all unstable.

Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction : randomized, placebo-
controlled trial. Lancet 2005 Nov 5
 CAUTION #3:
DO NOT WITHHOLD BETA-BLOCKER THERAPY FOR
INAPPROPRIATE REASONS
Elderly
Diabetes Mellitus
UAP/NSTEMI
Congestive Heart Failure
Hypertension
COPD
Despite convincing evidence of effectiveness, BB remain underutilized in
ED management of AMI, especially in the elderly.
The statistical mortality benefits for the elderly, diabetic,
COPD, UAP/NSTEMI, hypertension, and congestive heart
failure subgroups are all quite similar
 DOSAGES OF BETA-BLOCKERS AFTER
MYOCARDIAL INFARCTION
Metoprolol tartrate 25 to 50 mg every 6 to 12 h orally, then
transition over next 2 to 3 d to twice-daily dosing of metoprolol
tartrate or to daily metoprolol succinate; titrate to daily dose of
200 mg as tolerated
Carvedilol 6.25 mg twice daily, titrate to 25 mg twice daily as
tolerated
Metoprolol tartrate IV 5 mg every 5 min as tolerated up to 3
doses; titrate to heart rate and BP
Bisoprolol 1.25 mg once daily, titrate to 10 mgonce daily as
tolerated

ACCF/AHA Guideline for The Management of ST-Elevation Myocardial Infarction, 2013

ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment
elevation, 2012
 SUMMARY

NOT all of blockers are the same

On the day of admission, all patients should receive beta-
blocker therapy unless there are absolute contraindications or if
the patient is unstable.
If therapy was withheld because the patient was unstable, it
should be given once the patient is stable.
By the day of discharge, all patients should be on a beta-blocker
unless there is an absolute contraindication.
Before and After Reperfusion era, blockers are beneficial for
patients post myocardial infarction
 Take Home Message

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THANK YOU