Prevention of suboptimal beta-blocker treatment in patients with myocardial infarction

OBJECTIVE: To review the published data and clinical guidelines on the use of beta-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 beta-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 beta-blockers and long-term beta-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 beta-blockers are reviewed to allow the practitioner to identify patients who are incorrectly excluded from beta-blocker therapy. Also discussed are special clinical situations in which the benefits observed during clinical trials may not apply. CONCLUSIONS: Beta-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 beta-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.