Prevention of Suboptimal β-Blocker Treatment in Patients with Myocardial Infarction

Abstract

Spanish

French

OBJECTIVE:

To review the published data and clinical guidelines on the use of β-blockers in myocardial infarctions (MIs) and contrast that with actual clinical practice.

DATA SOURCES:

A MEDLINE search (January 1970–June 1999) was performed to identify all relevant articles. References from these articles were also evaluated for review if deemed important.

DATA SYNTHESIS:

Intravenous and oral β-blockers have been proven to improve outcomes in patients with MIs in numerous clinical trials. In current clinical practice, only 15% of MI patients receive intravenous β-blockers and long-term β-blocker therapy is used in <40% of patients without contraindications. However, they could be safely administered to 40% and 70% of these patients, respectively. Furthermore, most of these patients are receiving doses far below those found beneficial in clinical trials. Many of the real and perceived contraindications to β-blockers are reviewed to allow the practitioner to identify patients who are incorrectly excluded from β-blocker therapy. Also discussed are special clinical situations in which the benefits observed during clinical trials may not apply.

CONCLUSIONS:

β-blockers are valuable drugs in the treatment of peri-and post-MI. In clinical practice, most patients are not treated or are inadequately treated with β-blockers. Pharmacists should ensure that such patients actually have an absolute contraindication or unusual situation where therapy is not firmly indicated. Patients without absolute contraindications warrant titration to specific target doses or a target heart rate of 55–60 beats/min.

Keywords

β-blocker myocardial infarction contraindication mortality

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References

Thandroyen

Muntz

Buja

Willerson

. Alterations in beta-adrenergic receptor receptors, adenylate cyclase, and cyclic AMP concentrations during acute myocardial ischemia and reperfusion. Circulation 1990;82 (suppl 3): II30–7.

Lubbe

Podzuweit

Opie

. Potential arrhythmogenic role of cyclic adenosine monophosphate (AMP) and cytosolic calcium overload: Implications for prophylactic effects of beta-blockers in myocardial infarction and proarrhythmic effects of phosphodiesterase inhibitors. J Am Coll Cardiol 1992;19: 1622–33.

Townend

Vaile

Coote

. Preventing sudden cardiac death: The impact of beta-blockers on the brain. J Clin Pharm Ther 1995;20: 307–10.

Aupetit

Frassati

Bui-Xuan

Freysz

Faucon

Timour

. Efficacy of a beta-adrenergic antagonist, propranolol, in preventing ischemic ventricular fibrillation: Dependence on heart rate and ischemia duration. Cardiovasc Res 1998;37: 646–55.

Remeysen

De Clerck

. Antifibrillatory action of class I–IV antiarrhythmic agents in the model of ventricular fibrillation threshold of anesthetized guinea pigs. J Cardiovasc Pharmacol 1995;26: 132–6.

Tisdale

Sun

Zhao

Fan

Colucci

Kluger

Antifibrillatory effect of esmolol alone and in combination with lidocaine. J Cardiovasc Pharmacol 1996;27:376–82.

Wikstrand

Kendall

. The role of beta receptor blockade in preventing sudden death. Eur Heart J 1992;13 (suppl D): 111–20.

Skinner

. Regulation of cardiac vulnerability by the cerebral defense system. J Am Coll Cardiol 1985;5:88B–94B.

Parker

Michael

Hartley

Skinner

Entman

. Central beta-adrenergic mechanisms may modulate ischemic ventricular fibrillation in pigs. Circ Res 1990;66: 259–70.

10.

Ablad

Bjuro

Bjorkman

Edstrom

Olsson

. Role of central nervous beta-adrenoceptors in the prevention of ventricular fibrillation through augmentation of cardiac vagal tone (abstract). J Am Coll Cardiol 1991;17:1645A.

11.

Vanoli

DeFerrari

Stramba-Badiale

Hull

Foreman

Schwartz

. Vagal stimulation and prevention of sudden death in conscious dogs with a healed myocardial infarction. Circ Res 1991;68: 1471–81.

12.

Glancy

Garratt

Woods

de Bono

. QT dispersion and mortality after myocardial infarction. Lancet 1995;345: 945–8.

13.

Naka

Shiotani

Koretsune

Imai

Akamatsu

Hishida

Occurrence of sustained increase in QT dispersion following exercise in patients with residual myocardial ischemia after healing anterior wall myocardial infarction. Am J Cardiol 1997;80:1528–31.

14.

Roukema

Singh

Meijs

Cavalho

Hart

. Effect of exercise-induced ischemia on QT interval dispersion. Am Heart J 1998;135: 88–92.

15.

Musha

Kunishima

Awaya

Iwassaki

Nagashima

Nakamura

Influence of exercise on QT dispersion in ischemic heart disease. Jpn Heart J 1997;38:219–26.

16.

Ryan

Anderson

Antman

Braniff

Brooks

Califf

ACC AHA guidelines for the management of patients with acute myocardial infarction. J Am Coll Cardiol 1996;28:1328–428.

17.

Heilbrunn

Shah

Bristow

Valantine

Ginsburg

Fowler

. Increased beta-receptor density and improved hemodynamic response to catecholamines' stimulation during long-term metoprolol therapy in heart failure from dilated cardiomyopathy. Circulation 1989;79: 483–90.

18.

Eichorn

Heesch

Barnett

Alvarez

Fass

Grayburn

Effect of metoprolol on myocardial function and energetics in patients with nonischemic dilated cardiomyopathy: A randomized, double-blind, placebo-controlled study. J Am Coll Cardiol 1994;24:1310–20.

19.

Fischer

Gottlieb

Plotnick

Greenberg

Patten

Bennett

Beneficial effects of metoprolol in heart failure associated with coronary artery disease: A randomized trial. J Am Coll Cardiol 1994;23:943–50.

20.

Zipes

. Genesis of cardiac arrhythmias: Electrophysiological considerations. In: Braunwald

, ed. Braunwald heart disease. 5th ed. WB Saunders Co., 1997: 548–92.

21.

Kjekshus

. Importance of heart rate in determining beta-blocker efficacy in acute and long term acute myocardial intervention trials. Am J Cardiol 1986;57:43F–9F.

22.

McGorisk

Treasure

. Endothelial dysfunction in coronary artery disease. Curr Opin Cardiol 1996;11: 341–50.

23.

Mano

Masuyama

Yamamato

Kondo

Nanago

Tanouch

Endothelial dysfunction in the early stages of atherosclerosis precedes appearance of intimal lesions assessable with intravescular ultrasound. Am Heart J 1996;131:231–8.

24.

Bell

Johns

Lopez

. Endothelial dysfunction: Implications for therapy of cardiovascular diseases. Ann Pharmacother 1998;32: 459–70.

25.

Ercan

Turker

. Propranolol enhances acetylcholine induced relaxation in the various arterial segments of rabbit. Arch Intern Pharmacodyn 1988;294: 185–93.

26.

Kaplan

Manuck

Adams

Weingard

Clarkson

. Inhibition of coronary atherosclerosis by propranolol in behaviorally predisposed monkeys fed an atherogenic diet. Circulation 1987;76: 1364–72.

27.

Kjekshus

Pederson

Tobert

. Lipid lowering therapy for patients with or at risk of coronary artery disease. Curr Opin Cardiol 1996;11: 418–27.

28.

First International Study of Infarct Survival Collaborative Group. Randomised trial of intravenous atenolol among 16,027 cases of suspected acute myocardial infarction. ISIS-1. Lancet 1986;2: 57–66.

29.

Boissel

Leizorovicz

Picolet

Peyrieux

. For the APSI investigators. Secondary prevention after high risk acute myocardial infarction with low dose acebutolol. Am J Cardiol 1990;66: 251–60.

30.

Hjalmarson

Herlitz

Malek

Ryden

Vedin

Waldenstrom

Effect on mortality of metoprolol in acute myocardial infarction: A double-blind randomised trial. Lancet 1981;2:821–7.

31.

Norwegian Multicenter Study Group. Timolol-induced reduction in mortality and reinfarction in patients surviving acute myocardial infarction. N Engl J Med 1981;304:801–7.

32.

Pederson for the Norwegian Multicenter Study Group. Six year follow-up of the Norwegian Multicenter Study on timolol after acute myocardial infarction. N Engl J Med 1985;313:1055–8.

33.

Beta-Blocker Heart Attack Study Group. The Beta-Blockers Heart Attack Trial. JAMA 1981;246:2073–4.

34.

Lau

Antman

Jiminez-Silva

Kupelnick

Mosteller

Chalmers

. Cumulative meta-analysis of therapeutic trials for myocardial infarction. N Engl J Med 1992;327: 248–54.

35.

Hjalmarson

. Effects of beta-blockade on sudden cardiac death during acute myocardial infarction and the post-infarction period. Am J Cardiol 1997;80:35J–9J.

36.

The European Infarction Study Group (EIS). A secondary prevention study with slow release oxprenolol after myocardial infarction: Morbidity and mortality. Eur Heart J 1984;5: 189–202.

37.

Cucherat

Boissel

Leizorovicz

, for the APSI investigators. Persistent reduction of mortality for five years after one year of acebutolol treatment initiated during acute myocardial infarction. Am J Cardiol 1997;79: 587–9.

38.

Soriano

Meems

Grobbee

. Increased survival with beta-block-ers: Importance of ancillary properties. Prog Cardiovasc Dis 1997;39: 445–56.

39.

Basu

Senior

Raval

van der Does

Bruckner

Lahiri

. Beneficial effects of intravenous and oral carvedilol treatment in acute myocardial infarction: A placebo-controlled, randomized trial. Circulation 1997;96: 183–91.

40.

TIMI Study Group. Comparison of invasive and conservative strategies after treatment with intravenous tissue plasminogen activator in acute myocardial infarction: Results of the Thrombolysis in Myocardial Infarction (TIMI) Phase II Trial. N Engl J Med 1989;320:618–27.

41.

Vantrimpont

Rouleau

Wun

. for the SAVE investigators. Additive beneficial effects of beta-blockers to angiotensin-converting enzyme inhibitors in the Survival and Ventricular Enlargement (SAVE) study. J Am Coll Cardiol 1997;29: 229–36.

42.

Rogers

. Contemporary management of acute myocardial infarction. Am J Med 1995;99: 195–205.

43.

Rogers

Bowlby

Chandra

French

Gore

Lamrev

Treatment of myocardial infarction in the United States 1990–1993. Observations from the National Registry of Myocardial Infarction. Circulation 1994;90: 2103–14.

44.

Viskin

Kitzis

Lev

Zak

Heller

Villa

Treatment with beta-adrenergic blocking agents after myocardial infarction: From randomized trials to clinical practice. J Am Coll Cardiol 1995;25:1327–32.

45.

Barron

Viskin

Lundstrom

Wong

Swain

Truman

Beta-blocker doses and mortality after myocardial infarction: Data from a large health-maintenance organization. Arch Intern Med 1998;158:449–53.

46.

Brand

Newcomer

Freiburger

Tian

. Cardiologists' practices compared with practice guidelines: Use of beta-blockade after myocardial infarction. J Am Coll Cardiol 1995;26: 1432–6.

47.

McEvoy

, ed. American hospital formulary service drug information, American Society of Health-System Pharmacists. Bethesda, MD: ASHP, Inc., 1998.

48.

Antman

Braunwald

. Acute myocardial infarction. In: Braunwald

, ed. Braunwald heart disease. 5th ed. WB Saunders Co., 1997: 1184–288.

49.

Cummings

, ed. Arrhythmias. In: Advanced cardiac life support. New York: American Heart Association, Inc., 1994: 1–24.

50.

Kastrup

, ed. Drug facts and comparisons. St. Louis: Facts and Comparisons, Inc., 1998.

51.

White

Chow

MSS

. Cost-effectiveness of focused rounding in a cardiac intensive care unit. Hosp Pharm 1998;33: 419–23.

52.

The MIAMI Trial Research Group. Narcotic analgesics and other antianginal drugs. Am J Cardiol 1985;56:30G–4G.

53.

Herlitz

Waagstein

Lindqvist

Swedberg

Hjalmarson

. Effect of metoprolol on the prognosis for patients with suspected acute myocardial infarction and indirect signs of congestive heart failure (a subgroup analysis of the Goteberg Metoprolol Study). Am J Cardiol 1997;80:40J–4J.

54.

Chadda

Goldstein

Byington

Curb

. Effect of propranolol after acute myocardial infarction in patients with congestive heart failure. Circulation 1986;73: 503–10.

55.

Packer

Bristow

Cohn

Colucci

Fowler

Gilbert

The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. N Engl J Med 1996;334:1349–55.

56.

Van Herwaarden

. Beta-adrenoceptor blockade and pulmonary function in patients suffering from chronic obstructive lung disease. J Cardiovasc Pharmacol 1983;5 (suppl): s46–s50.

57.

Gold

Dee

Cocca-Spofford

Thompson

. Esmolol and ventilatory function in cardiac patients with COPD. Chest 1991;100: 1215–8.

58.

Skinner

Gaddie

Palmer

. Comparison of effects of metoprolol and propranolol on asthmatic airway obstruction. Br Med J 1976;282: 504.

59.

Benson

Berril

Sterling

DeCalmer

Chatterjee

Croxson

Cardioselective and non-cardioselective beta-blockers in reversible airways disease. Postgrad Med J 1977;53 (suppl 3):143–8.

60.

Sorbini

Grassi

Tantucci

Todisco

Motolese

Verdecchia

. Acute effects of oral metoprolol on ventilatory function in patients with chronic obstructive lung disease: Comparison of four increasing doses. Acta Therapeutica 1982;8: 5–14.

61.

Gottlieb

McCarter

Vogel

. Effect of beta-blockade on mortality among high risk and low risk patients after myocardial infarction. N Engl J Med 1998;339: 489–97.

62.

Hoffman

Lefkowitz

. Catecholamines, sympathetic drugs, and adrenergic receptor antagonists. In: Hardman

Limbird

. Goodman & Gilman's pharmacological basis of therapeutics. 9th ed. New York: McGraw-Hill, 1996: 199–248.

63.

Steil

. Diabetes mellitus. In: Dipiro

Talbert

Yee

, eds. Pharmacotherapy: a pathophysiologic approach. 3rd ed. Stamford, CT: Appleton and Lange, 1997: 1489–519.

64.

Coffman

Rasmussen

. Effects of beta-adrenoceptor blocking drugs in patients with Raynaud's phenomenon. Circulation 1985;72: 466–70.

65.

Nielson

Olsen

Nielson

. Increased digital arterial tone in hypertensive subjects treated with cardioselective and nonselective beta-adrenreceptor blocking agents. Dan Med Bull 1981;28: 76–80.

66.

Boden

. Management of non-Q-wave myocardial infarction: Role of diltiazem versus beta-blocker therapy. J Cardiovasc Pharmacol 1990;16 (suppl 6): s55–s60.

67.

Yusuf

Wittes

Probstfield

. Evaluating effects of treatment in subgroups of patients within a clinical trial: The case of non-Q-wave myocardial infarction and beta-blockers. Am J Cardiol 1990;66: 220–2.

68.

The MIAMI Trial Research Group. Mortality. Am J Cardiol 1985;56:15G–22G.

69.

Gheorghiade

Schultz

Tilley

Kao

Goldstein

. Effects of propranolol in non-Q-wave acute myocardial infarction in the Beta-Blocker Heart Attack Trial. Am J Cardiol 1990;66: 129–33.

70.

Pedersen

. for the Norwegian Multicenter Study Group. The Norwegian Multicenter study of timolol after myocardial infarction. Circulation 1983;67 (suppl I): 49–53.

71.

Overskeid

Abrahamsen

Frisvold

Von Der Lippe

Lund-Johanssen

Pedersen

. Response: Letter to the editor. N Engl J Med 1981;305: 407.

72.

Pitts

Lange

Cigarroa

Hillis

. Cocaine-induced myocardial ischemia and infarction: Pathophysiology, recognition, and management. Prog Cardiovasc Dis 1997;40: 65–76.

73.

Hoffman

Hollander

. Evaluation of patients with chest pain after cocaine use. Crit Care Clin 1997;13: 809–28.