β-Blockers in the Post–Myocardial Infarction Patient

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Abstract
Case 1: A 76-year-old man was diagnosed with an ST-segment elevation anterior wall myocardial infarction (MI) and underwent primary percutaneous coronary intervention with stent placement. After 3 days, the left ventricular ejection fraction was 35%. He was prescribed aspirin, clopidogrel, an angiotensin-converting enzyme (ACE) inhibitor, and a statin. Case 2: A 67-year-old woman with history of hypertension was diagnosed with a non–ST-elevation MI. The left ventricular ejection fraction was 50%. She initially was given an intravenous β-blocker, nitrates, aspirin, an ACE inhibitor, and a statin. Should long-term β-blockers be recommended for both of these patients? The 2001 American Heart Association and American College of Cardiology (AHA/ACC) guidelines for secondary prevention of MI and death recommend initiating β-blockade in all post-MI patients and continuing therapy indefinitely.1 Despite strong evidence supporting the use of β-blockers in the post-MI period, less than half of MI patients are prescribed β-blockers in the chronic setting.2,3⇓ Physician reluctance to use β-blockers after acute MI may be related to: (1) a perceived decline of benefits due to the introduction of antiplatelet agents, ACE inhibitors, statins, and revascularization procedures; (2) concerns about safety in patients with heart failure (HF), chronic obstructive pulmonary disease (COPD), diabetes mellitus, and/or old age; (3) side effect profile; and (4) perceived lack of benefit in non–ST-elevation MI. ### Use of β-Blockade in Contemporary Management of Post-MI Patients Since it was first reported in 1965 that administration of propranolol after acute MI reduced mortality,4 a number of studies have been conducted to confirm this observation.5 The largest were the β-Blocker Heart Attack Trial (BHAT)6 and the Norwegian Multicenter Study Group7 trial studying nonselective β-blockers. In the BHAT trial (which monitored 3837 post-MI patients for 27 months), propranolol significantly reduced overall mortality by 26% compared with placebo.8 The Norwegian Multicenter Study Group (which monitored 1884 post-MI patients …

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