Beta-blocker therapy after myocardial infarction: secondary prevention in all patients?
The ability of beta-adrenergic blocking drugs to prevent death in patients after myocardial infarction has been demonstrated by several large trials. However, the need to treat patients at low risk has been challenged. Retrospective analysis of the data from one of these studies plus results from many additional studies have shown that electrical, mechanical and ischemic complications after myocardial infarction imply a high risk of subsequent death or recurrent infarction. On the other hand, absence of complications with a negative exercise tolerance test, good exercise tolerance, absence of arrhythmias and normal increase of ejection fraction with exercise documents a very low risk. These considerations lead to the following practical implications: The physician should watch for any evidence of left ventricular dysfunction or arrhythmia. Any such complication justifies treatment or more intensive study. Patients without complications can be further characterized with exercise testing, exercise radionuclide blood pool ventriculography, and Holter monitoring. If these tests expose risk indicators, treatment or more study should again be recommended. Because the beta-blockers are probably life-saving in a considerable portion of the patients with moderate and high risk, the decision to treat or not to treat should be made with due, affirmative consideration. In those patients with a carefully documented uncomplicated course and who have a normal exercise test and appropriate increase in ventricular ejection fraction with stress, beta-blockade is probably of no benefit. Under these conditions, a physician and patient might logically decide not to use the drug.
Griggs
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T
Adams
K
K
Narvarte
H
H
Sheps
D
D
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D001145:Arrhythmias, Cardiac / Q000209:etiology; D004562:Electrocardiography; D005080:Exercise Test; D006321:Heart / Q000503:physiopathology; D006801:Humans; D008991:Monitoring, Physiologic; D009203:Myocardial Infarction / Q000503:physiopathology / Q000517:prevention & control*; D011433:Propranolol / Q000627:therapeutic use; D012008:Recurrence; D012189:Retrospective Studies; D012306:Risk
D000319:Adrenergic beta-Antagonists; D011433:Propranolol