Cardiology Division, Geneva University Hospitals, Geneva, Switzerland.
Institute of Primary Healthcare (BIHAM), University of Bern, Bern, Switzerland.
Eur J Clin Invest. 2024 Dec;54(12):e14309. doi: 10.1111/eci.14309. Epub 2024 Sep 10.
Beta-blocker therapy, a treatment burdened by side effects including fatigue, erectile dysfunction and depression, was shown to reduce mortality and cardiovascular events after acute coronary syndromes (ACS) in the pre-coronary reperfusion era. Potential mechanisms include protection from ventricular arrhythmias, increased ischaemia threshold and prevention of left ventricular (LV) adverse remodelling. With the advent of early mechanical reperfusion and contemporary pharmacologic secondary prevention, the benefit of beta-blockers after ACS in the absence of LV dysfunction has been challenged.
The present narrative review discusses the contemporary evidence based on searching the PubMed database and references in identified articles.
Recently, the REDUCE-AMI trial-the first adequately powered randomized trial in the reperfusion era to test beta-blocker therapy after myocardial infarction with preserved left ventricular ejection fraction (LVEF)-showed no benefit on the composite of all-cause death or myocardial infarction over a median 3.5-year follow-up. While the benefit of beta-blockers in patients with reduced LVEF remains undisputed, their value in post-ACS patients with mildly reduced systolic function (LVEF 41%-49%) has not been studied in contemporary randomized trials; in this setting, observational studies have suggested a reduction in cardiovascular events with these agents. The adequate duration of beta-blocker therapy remains unknown, but observational data suggests that any mortality benefit may be lost beyond 1-12 months after ACS in patients with LVEF >40%.
We believe that there is sufficient evidence to abandon routine beta-blocker prescription in post-ACS patients with preserved LV systolic function.
β受体阻滞剂治疗在急性冠状动脉综合征（ACS）后具有降低死亡率和心血管事件的作用，但它也会引起疲劳、勃起功能障碍和抑郁等副作用。在冠状动脉再灌注前时代，β受体阻滞剂治疗已经被证明可以降低死亡率和心血管事件。潜在的机制包括预防室性心律失常、提高缺血阈值和防止左心室（LV）不良重构。随着早期机械再灌注和当代药物二级预防的出现，ACS 后 LV 功能正常的患者使用β受体阻滞剂的获益受到了质疑。
本综述讨论了通过搜索 PubMed 数据库和已确定文章的参考文献获得的当代证据。
最近，REVERSE-AMI 试验——再灌注时代第一项在心肌梗死后射血分数保留（LVEF）的患者中进行的评估β受体阻滞剂治疗的充分规模随机试验——在中位 3.5 年的随访中，并未显示在全因死亡或心肌梗死的复合终点方面有获益。虽然β受体阻滞剂在射血分数降低的患者中的获益仍然无可争议，但它们在 ACS 后轻度收缩功能障碍（LVEF 41%-49%）的患者中的价值尚未在当代随机试验中得到研究；在这种情况下，观察性研究表明这些药物可以减少心血管事件。β受体阻滞剂治疗的合适持续时间尚不清楚，但观察性数据表明，在 ACS 后 LVEF>40%的患者中，超过 1-12 个月后，任何死亡率获益可能会消失。
我们认为，有足够的证据可以放弃 ACS 后 LV 收缩功能正常的患者常规使用β受体阻滞剂。
