Beta-Blocker Therapy After Myocardial Infarction

Abstract

Historical data strongly supported the benefits of beta-blocker therapy following a myocardial infarction (MI) for its efficacy in reducing mortality and morbidity. However, in the context of the progressive evolution of treatment strategies for MI patients, the apparent benefit of beta-blocker therapy is becoming less clear. In particular, its effectiveness in patients with preserved left ventricular ejection fraction is currently being challenged. Consequently, contemporary guidelines are now varying in their recommendations regarding the role of beta-blocker therapy in post-MI patients. This review aims to summarize and compare the largest and most influential studies from the prereperfusion era to modern practice regarding different health outcomes while highlighting the need for further research to clarify beta-blocker therapy's place in contemporary post-MI management.

Keywords: CVD; beta-blockers; myocardial infarction.

Graphical abstract

Central Illustration

Timeline and Traffic Light Summary of Randomized Controlled Trials Assessing the Association Between Beta-Blocker Therapy With Mortality and Morbidity The timeline illustrates included randomized controlled trials during the prereperfusion and reperfusion eras, with a traffic light color coding indicating the type of association between beta-blocker therapy and patient outcomes. The timeline highlights how evidence has evolved over time with the introduction of new treatments and shifts in patient populations, offering insights into the changing clinical context and treatment efficacy. RCTs = randomized controlled trials.

Figure 1

American Heart Association/American College of Cardiology Guidelines: Long-Term Beta-Blocker Therapy for Post-Myocardial Infarction Prevention This figure summarizes key updates in the AHA/ACC guidelines for beta-blocker use in secondary prevention after MI, from 2011 to 2023. It shows evolving recommendations, class of recommendation, and level of evidence, including various patient populations such as those with left ventricular dysfunction, heart failure, and CAD. The figure also highlights changes in treatment duration, patient selection, and specific beta-blocker medications. ACS = acute coronary syndrome; AHA/ACC = American Heart Association/American College of Cardiology; CAD = coronary artery disease; LVEF = left ventricular ejection fraction; MACE = major adverse cardiac events; MI = myocardial infarction; STEMI = ST-segment elevation myocardial infarction.

Figure 2

ESC Guidelines: Long-Term Beta-Blocker Therapy for Post-Myocardial Infarction Prevention This figure illustrates key updates in the ESC guidelines on beta-blocker therapy for secondary prevention following MI, from 2017 to 2023. It highlights evolving recommendations for patients with LVEF ≤40%, heart failure, and a history of MI, as well as the class of recommendation and level of evidence for beta-blocker use in ACS and chronic coronary syndromes. The figure also reflects a shift toward broader use of beta-blockers in ACS patients, regardless of heart failure status. ESC = European Society of Cardiology; other abbreviations as in Figure 1.

Figure 3

NHFA/CSANZ Guidelines: Long-Term Beta-Blocker Therapy for Post-Myocardial Infarction Prevention This figure summarizes the 2016 NHFA and CSANZ guidelines on beta-blocker use for secondary prevention after MI. It emphasizes initiating beta-blockers in patients with reduced LVEF (≤40%) unless contraindicated, with a class IIa recommendation and level a evidence for this high-risk group. NHFA/CSANZ = National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand; other abbreviations as in Figure 1.