Use of Beta Adrenoceptor Blockade During and After Acute Myocardial Infarction

In the last year, two large randomized controlled trials of metoprolol (MIAMI, almost 6,000 patients) and atenolol (ISIS 1, over 16,000 patients) given intravenously within 12 hours of the onset of acute myocardial infarction reduced mortality by about 15% in low-risk subjects. The reduction was significant for atenolol (2P = 0.04) but not for metoprolol, probably because of the smaller size of that trial. The reduction in mortality in both trials was nearly all in the first 36 hours, a finding that reduced the fears that the treatment might produce irreversible failure, shock, or heart block. Tolerance in these relatively low-risk subjects (control mortality about 5%) was good. Inotropes were used in 1-2% more subjects in the beta-blocked group but were effective in reversing the side effects without increasing mortality. No clear subgroups (age, sex, site, time from onset, initial blood pressure or heart rate) were found in which treatment was more beneficial. In the ISIS study, patients with higher heart rates were more likely to need inotropes after beta blockade and patients with long PR intervals at entry were more likely to develop block. Neither of these complications resulted in excess mortality in the blocked group, which suggests that these adverse effects were largely reversible.