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Acute myocardial infarction: Role of beta blocker therapy

Robert S Rosenson, MD
Guy S Reeder, MD
Harold L Kennedy, MD, MPH
Section Editor
Christopher P Cannon, MD
Deputy Editor
Gordon M Saperia, MD, FACC


For patients with acute myocardial infarction (MI), beta blocker therapy reduces infarct size and early mortality when started early and lowers the risk of death when continued long term. (See "Overview of the acute management of ST elevation myocardial infarction" and "Overview of the acute management of unstable angina and non-ST elevation myocardial infarction" and "Prevention of cardiovascular disease events in those with established disease or at high risk".)

This topic will discuss the use of beta blockers in patients with acute MI and focus on those without heart failure or reduced left ventricular systolic dysfunction [1]. Other relevant issues regarding beta blockers are discussed elsewhere. (See "Major side effects of beta blockers" and "Use of beta blockers in heart failure with reduced ejection fraction" and "Prophylaxis against ventricular arrhythmias during and after acute myocardial infarction" and "Clinical features and treatment of ventricular arrhythmias during acute myocardial infarction".)


Potentially beneficial effects of beta blockers in patients with acute myocardial infarction (MI) include [2]:

Decreased oxygen demand due to the reductions in heart rate, blood pressure, and contractility, and the consequent relief of ischemic chest pain.

Decreased risk of ventricular fibrillation as suggested by experimental studies demonstrating an increase in the ventricular fibrillation threshold and by clinical trials showing a relative risk reduction in sudden cardiac death (eg, 30 to 47 percent) [3-5].


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Literature review current through: Jul 2017. | This topic last updated: Jul 10, 2017.
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  1. Anderson JL, Morrow DA. Acute Myocardial Infarction. N Engl J Med 2017; 376:2053.
  2. López-Sendón J, Swedberg K, McMurray J, et al. Expert consensus document on beta-adrenergic receptor blockers. Eur Heart J 2004; 25:1341.
  3. Rydén L, Ariniego R, Arnman K, et al. A double-blind trial of metoprolol in acute myocardial infarction. Effects on ventricular tachyarrhythmias. N Engl J Med 1983; 308:614.
  4. Nuttall SL, Toescu V, Kendall MJ. beta Blockade after myocardial infarction. Beta blockers have key role in reducing morbidity and mortality after infarction. BMJ 2000; 320:581.
  5. Friedman LM, Byington RP, Capone RJ, et al. Effect of propranolol in patients with myocardial infarction and ventricular arrhythmia. J Am Coll Cardiol 1986; 7:1.
  6. Hu K, Gaudron P, Ertl G. Long-term effects of beta-adrenergic blocking agent treatment on hemodynamic function and left ventricular remodeling in rats with experimental myocardial infarction: importance of timing of treatment and infarct size. J Am Coll Cardiol 1998; 31:692.
  7. Galcerá-Tomás J, Castillo-Soria FJ, Villegas-García MM, et al. Effects of early use of atenolol or captopril on infarct size and ventricular volume: A double-blind comparison in patients with anterior acute myocardial infarction. Circulation 2001; 103:813.
  8. Doughty RN, Whalley GA, Walsh HA, et al. Effects of carvedilol on left ventricular remodeling after acute myocardial infarction: the CAPRICORN Echo Substudy. Circulation 2004; 109:201.
  9. Poulsen SH, Jensen SE, Egstrup K. Effects of long-term adrenergic beta-blockade on left ventricular diastolic filling in patients with acute myocardial infarction. Am Heart J 1999; 138:710.
  10. Sipahi I, Tuzcu EM, Wolski KE, et al. Beta-blockers and progression of coronary atherosclerosis: pooled analysis of 4 intravascular ultrasonography trials. Ann Intern Med 2007; 147:10.
  11. Mak IT, Weglicki WB. Protection by beta-blocking agents against free radical-mediated sarcolemmal lipid peroxidation. Circ Res 1988; 63:262.
  12. Norwegian Multicenter Study Group. Timolol-induced reduction in mortality and reinfarction in patients surviving acute myocardial infarction. N Engl J Med 1981; 304:801.
  13. Hjalmarson A, Herlitz J, Holmberg S, et al. The Göteborg metoprolol trial. Effects on mortality and morbidity in acute myocardial infarction. Circulation 1983; 67:I26.
  14. Chadda K, Goldstein S, Byington R, Curb JD. Effect of propranolol after acute myocardial infarction in patients with congestive heart failure. Circulation 1986; 73:503.
  15. Metoprolol in acute myocardial infarction (MIAMI). A randomised placebo-controlled international trial. The MIAMI Trial Research Group. Eur Heart J 1985; 6:199.
  16. Randomised trial of intravenous atenolol among 16 027 cases of suspected acute myocardial infarction: ISIS-1. First International Study of Infarct Survival Collaborative Group. Lancet 1986; 2:57.
  17. Yusuf S, Peto R, Lewis J, et al. Beta blockade during and after myocardial infarction: an overview of the randomized trials. Prog Cardiovasc Dis 1985; 27:335.
  18. Green BK, Gordon GD, Horak AR, et al. Safety of combined intravenous beta-adrenergic blockade (atenolol or metoprolol) and thrombolytic therapy in acute myocardial infarction. Am J Cardiol 1992; 69:1389.
  19. Risenfors M, Herlitz J, Berg CH, et al. Early treatment with thrombolysis and beta-blockade in suspected acute myocardial infarction: results from the TEAHAT Study. J Intern Med Suppl 1991; 734:35.
  20. Boissel JP, Leizorovicz A, Picolet H, Peyrieux JC. Secondary prevention after high-risk acute myocardial infarction with low-dose acebutolol. Am J Cardiol 1990; 66:251.
  21. Gottlieb SS, McCarter RJ, Vogel RA. Effect of beta-blockade on mortality among high-risk and low-risk patients after myocardial infarction. N Engl J Med 1998; 339:489.
  22. Van de Werf F, Janssens L, Brzostek T, et al. Short-term effects of early intravenous treatment with a beta-adrenergic blocking agent or a specific bradycardiac agent in patients with acute myocardial infarction receiving thrombolytic therapy. J Am Coll Cardiol 1993; 22:407.
  23. Freemantle N, Cleland J, Young P, et al. beta Blockade after myocardial infarction: systematic review and meta regression analysis. BMJ 1999; 318:1730.
  24. Kernis SJ, Harjai KJ, Stone GW, et al. Does beta-blocker therapy improve clinical outcomes of acute myocardial infarction after successful primary angioplasty? J Am Coll Cardiol 2004; 43:1773.
  25. Nakatani D, Sakata Y, Suna S, et al. Impact of beta blockade therapy on long-term mortality after ST-segment elevation acute myocardial infarction in the percutaneous coronary intervention era. Am J Cardiol 2013; 111:457.
  26. Ozasa N, Kimura T, Morimoto T, et al. Lack of effect of oral beta-blocker therapy at discharge on long-term clinical outcomes of ST-segment elevation acute myocardial infarction after primary percutaneous coronary intervention. Am J Cardiol 2010; 106:1225.
  27. Yang JH, Hahn JY, Song YB, et al. Association of beta-blocker therapy at discharge with clinical outcomes in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. JACC Cardiovasc Interv 2014; 7:592.
  28. Huang BT, Huang FY, Zuo ZL, et al. Meta-Analysis of Relation Between Oral β-Blocker Therapy and Outcomes in Patients With Acute Myocardial Infarction Who Underwent Percutaneous Coronary Intervention. Am J Cardiol 2015; 115:1529.
  29. Dondo TB, Hall M, West RM, et al. β-Blockers and Mortality After Acute Myocardial Infarction in Patients Without Heart Failure or Ventricular Dysfunction. J Am Coll Cardiol 2017; 69:2710.
  30. Roberts R, Rogers WJ, Mueller HS, et al. Immediate versus deferred beta-blockade following thrombolytic therapy in patients with acute myocardial infarction. Results of the Thrombolysis in Myocardial Infarction (TIMI) II-B Study. Circulation 1991; 83:422.
  31. 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.
  32. Chen ZM, Pan HC, Chen YP, et al. Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet 2005; 366:1622.
  33. Barron HV, Rundle AC, Gore JM, et al. Intracranial hemorrhage rates and effect of immediate beta-blocker use in patients with acute myocardial infarction treated with tissue plasminogen activator. Participants in the National Registry of Myocardial Infarction-2. Am J Cardiol 2000; 85:294.
  34. Teo KK, Yusuf S, Furberg CD. Effects of prophylactic antiarrhythmic drug therapy in acute myocardial infarction. An overview of results from randomized controlled trials. JAMA 1993; 270:1589.
  35. Ibanez B, Macaya C, Sánchez-Brunete V, et al. Effect of early metoprolol on infarct size in ST-segment-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention: the Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction (METOCARD-CNIC) trial. Circulation 2013; 128:1495.
  36. Pizarro G, Fernández-Friera L, Fuster V, et al. Long-term benefit of early pre-reperfusion metoprolol administration in patients with acute myocardial infarction: results from the METOCARD-CNIC trial (Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction). J Am Coll Cardiol 2014; 63:2356.
  37. Roolvink V, Ibáñez B, Ottervanger JP, et al. Early Intravenous Beta-Blockers in Patients With ST-Segment Elevation Myocardial Infarction Before Primary Percutaneous Coronary Intervention. J Am Coll Cardiol 2016; 67:2705.
  38. Halkin A, Grines CL, Cox DA, et al. Impact of intravenous beta-blockade before primary angioplasty on survival in patients undergoing mechanical reperfusion therapy for acute myocardial infarction. J Am Coll Cardiol 2004; 43:1780.
  39. Writing Group Members, Mozaffarian D, Benjamin EJ, et al. Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. Circulation 2016; 133:e38.
  40. GBD 2013 DALYs and HALE Collaborators, Murray CJ, Barber RM, et al. Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: quantifying the epidemiological transition. Lancet 2015; 386:2145.
  41. Kennedy HL, Brooks MM, Barker AH, et al. Beta-blocker therapy in the Cardiac Arrhythmia Suppression Trial. CAST Investigators. Am J Cardiol 1994; 74:674.
  42. Bangalore S, Steg G, Deedwania P, et al. β-Blocker use and clinical outcomes in stable outpatients with and without coronary artery disease. JAMA 2012; 308:1340.
  43. Goldberger JJ, Bonow RO, Cuffe M, et al. Effect of Beta-Blocker Dose on Survival After Acute Myocardial Infarction. J Am Coll Cardiol 2015; 66:1431.
  44. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction. www.acc.org/qualityandscience/clinical/statements.htm (Accessed on August 24, 2006).
  45. www.acc.org/qualityandscience/clinical/statements.htm (Accessed on September 18, 2007). www.acc.org/qualityandscience/clinical/statements.htm (Accessed on September 18, 2007).
  46. Shivkumar K, Schultz L, Goldstein S, Gheorghiade M. Effects of propanolol in patients entered in the Beta-Blocker Heart Attack Trial with their first myocardial infarction and persistent electrocardiographic ST-segment depression. Am Heart J 1998; 135:261.
  47. Kjekshus JK. Importance of heart rate in determining beta-blocker efficacy in acute and long-term acute myocardial infarction intervention trials. Am J Cardiol 1986; 57:43F.
  48. Cucherat M. Quantitative relationship between resting heart rate reduction and magnitude of clinical benefits in post-myocardial infarction: a meta-regression of randomized clinical trials. Eur Heart J 2007; 28:3012.
  49. Spargias KS, Hall AS, Greenwood DC, Ball SG. beta blocker treatment and other prognostic variables in patients with clinical evidence of heart failure after acute myocardial infarction: evidence from the AIRE study. Heart 1999; 81:25.
  50. Dargie HJ. Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomised trial. Lancet 2001; 357:1385.
  51. Lichstein E, Hager WD, Gregory JJ, et al. Relation between beta-adrenergic blocker use, various correlates of left ventricular function and the chance of developing congestive heart failure. The Multicenter Diltiazem Post-Infarction Research Group. J Am Coll Cardiol 1990; 16:1327.
  52. Chen J, Radford MJ, Wang Y, et al. Effectiveness of beta-blocker therapy after acute myocardial infarction in elderly patients with chronic obstructive pulmonary disease or asthma. J Am Coll Cardiol 2001; 37:1950.
  53. Vantrimpont P, Rouleau JL, Wun CC, et al. Additive beneficial effects of beta-blockers to angiotensin-converting enzyme inhibitors in the Survival and Ventricular Enlargement (SAVE) Study. SAVE Investigators. J Am Coll Cardiol 1997; 29:229.
  54. Exner DV, Dries DL, Waclawiw MA, et al. Beta-adrenergic blocking agent use and mortality in patients with asymptomatic and symptomatic left ventricular systolic dysfunction: a post hoc analysis of the Studies of Left Ventricular Dysfunction. J Am Coll Cardiol 1999; 33:916.
  55. Gundersen T, Kjekshus J. Timolol treatment after myocardial infarction in diabetic patients. Diabetes Care 1983; 6:285.
  56. Malmberg K, Herlitz J, Hjalmarson A, Rydén L. Effects of metoprolol on mortality and late infarction in diabetics with suspected acute myocardial infarction. Retrospective data from two large studies. Eur Heart J 1989; 10:423.
  57. Quint JK, Herrett E, Bhaskaran K, et al. Effect of β blockers on mortality after myocardial infarction in adults with COPD: population based cohort study of UK electronic healthcare records. BMJ 2013; 347:f6650.
  58. Califf RM, Lokhnygina Y, Velazquez EJ, et al. Usefulness of beta blockers in high-risk patients after myocardial infarction in conjunction with captopril and/or valsartan (from the VALsartan In Acute Myocardial Infarction [VALIANT] trial). Am J Cardiol 2009; 104:151.
  59. Radack K, Deck C. Beta-adrenergic blocker therapy does not worsen intermittent claudication in subjects with peripheral arterial disease. A meta-analysis of randomized controlled trials. Arch Intern Med 1991; 151:1769.
  60. Solomon SA, Ramsay LE, Yeo WW, et al. beta blockade and intermittent claudication: placebo controlled trial of atenolol and nifedipine and their combination. BMJ 1991; 303:1100.
  61. Boutitie F, Boissel JP, Connolly SJ, et al. Amiodarone interaction with beta-blockers: analysis of the merged EMIAT (European Myocardial Infarct Amiodarone Trial) and CAMIAT (Canadian Amiodarone Myocardial Infarction Trial) databases. The EMIAT and CAMIAT Investigators. Circulation 1999; 99:2268.
  62. Smith SC Jr, Benjamin EJ, Bonow RO, et al. AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation 2011; 124:2458.
  63. Roffi M, Patrono C, Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016; 37:267.