BETA BLOCKERS IN ISCHEMIC HEART DISEASE AS ...
BETA BLOCKERS IN ISCHEMIC HEART DISEASE AS “CARDIOPROTECTION” IN THE ERA OF ACE INHIBITION AND RAPID REVASCULARIZATION
B.F. Uretsky
University of Texas Medical Branch at Galveston, Galveston, TX, U.S.A.
Most of the evidence to support the use of beta blockers in ischemic heart disease for cardioprotection was gathered prior to the era in which therapies such as ACE inhibition, platelet inhibition, and rapid revascularization for acute coronary syndromes was well established. It is reasonable, therefore, to review current recommendations for beta blocker use as cardioprotective agents in this light.
The ACC/AHA guidelines recommends as a Class I indication beta blockade post-Q wave MI in all pts except those with difficult to control heart failure. The CAPRICORN trial using carvedilol has confirmed earlier studies on the value of beta blocker in decreasing mortality and recurrent myocardial infarction. On the other hand, meta-analyses suggest that the very early use of intravenous beta blocker has only a limited value in decreasing mortality. Data to support the value of beta blockers as cardioprotective agents in stable and unstable angina are inferred and based in large part on the results of post-MI studies. Finally, in high-risk surgical patients, beta blockers seem to be cardioprotective when given pre-operatively although the length of time pre-operatively and post-operatively are not as clear.
A new use of beta blocker is during coronary angioplasty (PCI). In this setting, the drug is given intra-coronary at relatively high doses to avoid systemic adverse effects, hypotension, and bradycardia. In a recent prospective randomized trial, such an approach markedly decrease post-PCI myocardial infarction and improved short-term clinical outcome.
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