Should β-blockers still be routine after myocardial infarction?

PURPOSE OF REVIEW: This review will assess whether the 25-year-old evidence base to support routine prescribing of β-blockers after myocardial infarction (MI) is relevant to modern management. RECENT FINDINGS: The evidence base to support the recommendation for the widespread use of β-blockers after MI was near-finalized in the mid-1980s. Whereas the use of intravenous β-blockers is waning, the routine use of oral β-blockers after MI is still regarded as evidence based. In the past 25 years, the introduction of coronary reperfusion and of effective nonreperfusion therapies has changed the natural history of MI and there have been substantial changes in the definition of MI. The relevance of old clinical trial data collected in patients who bear little resemblance to today's MI patients is questioned. Recent analyses have shown that there is no convincing evidence for the use of β-blockers as first-line therapy in hypertension or in patients with stable coronary heart disease. In contrast, the evidence base for the use of β-blockers in heart failure is strong and contemporary. SUMMARY: A rational recommendation for the modern treatment of MI would be to limit the use of β-blockers in the post-MI patient to higher-risk patients with evidence of ongoing ischemia, heart failure, or left ventricular dysfunction. There is no evidence to support the routine use of oral β-blockers in low-risk MI patients.