Do All Patients Need β-Blockers After a Heart Attack?

Angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARB), beta-blockers and statins are recommended after acute myocardial infarction(AMI).Two large observational studies published last year in the Journal of the American College of Cardiology (JACC) have raised questions about the rationale of use of β-blockers in all patients after a first heart attack. Dr. Jennifer Abbasi in an article published online in JAMA. has outlined very vividly various aspects of using of beta blockers in MI.

Salient Points-

1. β-Blockers were approved in the 1980s for use in patients recovering from myocardial infarction (MI) after 2 large RCTs—the β-Blocker Heart Attack Trial (BHAT) and the Norwegian Multicenter Study Group trial—conclusively demonstrated that the agents reduced the risk of a second heart attack and death.


2. 1999 review of 31 long-term RCTs confirmed their life-saving value after a heart attack.


3. Multiple large trials have since confirmed the drugs’ benefit in people with heart failure. But β-blockers have not been tested in a large, contemporary trial involving people who had a heart attack but don’t have heart failure.


4. In 2011 Update American Heart Association (AHA) and the American College of Cardiology Foundation (ACCF) recommend that, barring contraindications, all patients should receive β-blockers after a heart attack to prevent a second one and continue taking them for at least 3 years.


5. In the Poststatin Era Jennifer G. Robinson found that β-blockers may not be needed as long as patients take both statins and ACE inhibitors or ARBs, and as long as there aren’t other indications, such as heart failure or arrhythmia.The studies have shown that as it is the patients who are on 3 drugs in most of cases don't take all three.


6. In 2015 meta-analysis it was found that β-blockers certainly benefit in people with heart failure.In patients with PCI after MI β-blocker use was associated with a reduced risk of death only in certain patients, including those with reduced ejection fraction—a form of heart failure—or low use of other prophylactic drugs.


7. Gale and a team of European researchers found no survival benefit of β-blockers at any time point up to 1 year after hospitalization for patients who had a heart attack but did not have heart failure or left ventricular systolic dysfunction (LVSD).


8. β-blocker use was associated with lower 30-day mortality but not lower 5-year mortality, suggesting that long-term use may not save lives.


9. Unlike the US guidelines, European guidelines don’t recommend β-blockers as a first-line prophylactic therapy for MI for all patients.


10. Experts are of the opinion that it is Time for Trials and future studies are needed to settle the issue.