Stopping β-Blockers After Myocardial Infarction
Not So Fast!
This article requires a subscription to view the full text. If you have a subscription you may use the login form below to view the article. Access to this article can also be purchased.
See Article by Neumann et al
For more than 3 decades, β-blockers have been the mainstay of medical treatment for patients with myocardial infarction (MI). By the mid-1980s, landmark studies by the Norwegian study group, the North American BHAT (Beta-Blocker Heart Attack Trial), and the ISIS-I (First International Study of Infarct Survival) had firmly established the ability of β-blockers to reduce mortality in MI.1 A meta-analysis by Freemantle et al1 of 82 randomized trials encompassing 54 234 MI patients found that β-blockers reduced the odds of death by 23% when used for longer than 6 months. Despite the overwhelming clinical importance in support of the use of β-blockers in reducing mortality, substantial underutilization persisted through the 1990s, such that only 1 in 2 ideal patients >65 years were prescribed therapy after hospitalization for an MI.2 These observations stimulated research to evaluate barriers of treatment, dispel misconceptions of β-blockers, and optimize treatment implementation. It also created a culture of ongoing quality improvement such that by the 2000s, the use of β-blockers after MI became so consistent that ongoing tracking as a quality indicator was no longer needed.
Since the widespread adoption of β-blockers, there have been many advances in the treatment of MI such as dual antiplatelet therapy, statins, angiotensin-converting enzyme inhibitors, fibrinolytic therapy, and percutaneous coronary interventions. There have also been advances in the diagnostic ability of MI with the introduction of normal and high-sensitivity troponin assays that allow for identification of smaller infarctions. These factors have resulted in a substantial and progressive reduction in the risk of dying after an MI over the past several decades. This led investigators to question whether β-blockers, one of the earliest post-MI therapies, were still beneficial in this setting. Using data from the REACH registry (Reduction of Atherothrombosis for Continued Health), …