Rethinking the Use of Beta-Blockers After a Myocardial Infarction

Beta-blockers have long been considered a foundational therapy following myocardial infarction, yet emerging data are challenging their routine use in all patients. This course discusses recent evidence on outcomes associated with beta-blocker therapy after MI, particularly in patients without reduced ejection fraction, and explores the ongoing debate over the benefits, risks, and duration of therapy. You will gain practical insight to support evidence-based decision-making and individualized pharmacotherapy recommendations in post-MI care.
 

HOST
Rachel Maynard, PharmD
GameChangers Podcast Host and Lead, Clinical & Partnership Education, CEimpact

GUEST
Anna Crider, PharmD, BCCP
Clinical Pharmacy Specialist,
Emory University Hospital

Taylor Merritt, PharmD
PGY2 Internal Medicine Pharmacy Resident, Chief Pharmacy Resident,
Emory University Hospital

 
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CPE INFORMATION
 Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Summarize contemporary evidence regarding beta-blocker therapy after myocardial infarction.
2. Describe clinical considerations that may influence the decision to initiate, continue, or deprescribe beta-blocker therapy following myocardial infarction.

Rachel Maynard, Anna Crider, and Taylor Merritt have no relevant financial relationships to disclose.

0.075 CEU/0.75 Hr
UAN: 0107-0000-26-242-H01-P
Initial release date: 6/29/2026
Expiration date: 6/29/2027
Additional CPE details can be found here.

Transcript

Welcome And The Big Debate

Speaker 2 0:00

Hi Health Mart Pharmacists, from your education partner CE Impact, this is Game Changers. I'm your host, Jen Moulton, and each week we have a conversation on a hot clinical topic that will keep you current in practice and position you as a resource for prescribers and patients. Thanks for listening in.

Speaker 3 0:18

Welcome to the Game Changers Clinical Update Podcast. I'm your host, Rachel Maynard. And I'm excited to dive into our discussion today. We have two guests joining us, and we'll be debating a topic that's gotten some buzz recently. So for decades, beta blockers have been a cornerstone of therapy after myocardial infarction. But the merging evidence is now challenging whether beta blockers should be used in all patients post-MI. So to learn about what's changed and what we need to consider going forward, we have two expert voices in this discussion, one in favor of continued use of beta blockers post-MI and one opposed to help us weigh the pros and cons of each approach and how we as pharmacists can help navigate those clinical gray areas. So I'm thrilled to welcome Dr. Anna Kreider and Dr. Taylor Merritt as our guests for this episode to help weigh in on this debate. So welcome Anna and Taylor.

Speaker 1:06

Thanks so much. Happy to be here. My name is Anna Kreider. I am one of the cardiology clinical specialists here at Emory University Hospital. I did my PGY1 and PGY2 training after pharmacy school at Brigham and Women's Hospital in Boston, Massachusetts. And then I've been in my current role for the past almost four years. And I really enjoy talking about everything cardiology. And so I'm glad there's kind of some more data coming out about beta blockers. And as pharmacists, we always love to de-prescribe or at least make sure we're optimized medication therapy. So I'm excited to have this debate today.

Speaker 3 1:41

Fantastic. Yeah, absolutely. Great perspective and great expertise you're bringing to this discussion. Taylor, how about you? We'd love to hear a little bit about your background as well.

Speaker 1 1:50

Yes, hi, and thank you so much for having me again. I'm happy to be here. I have a little bit of a different background. So I'm currently the PGY2 internal medicine pharmacy resident, also at Emory University Hospital, where I did my PGY1 training as well. So I've had a variety of different experiences this year, but um a couple of heart failure rotations and cardiology focus as well. Um also worked with Anna in various capacities as a preceptor. So have a little bit of experience in the cardiology world, um, but excited to kind of have this conversation. It's something we definitely see both from a very heavy cardiology perspective, but with our internal medicine patients a lot too. So excited for us to have this conversation today.

Speaker 3 2:30

Yeah, that's exactly what I was gonna say, Taylor, is uh the internal medicine background is also very relevant because this is our Brandon Brother sort of, you know, patients we see every day, regardless of the practice setting we're in, I think. So fantastic.

Why Beta Blockers Became Standard

Speaker 3 2:41

So let's go ahead and set the stage for our listeners and just make sure we're aligned in terms of how myocardial infarction is currently managed and the role of beta blockers from a pathophysiologic perspective. So I think that's gonna help us lay that groundwork for why we've been so used to seeing beta blockers use post MI for decades, I think. So, Anna, do you want to start that part of the discussion and lay that groundwork for us?

Speaker 3:02

Yeah, absolutely. I think beta blockers are unlike other meds that we now have coming out of the word works, they have so much data behind them. And they have data of essentially in the MI space before we had reperfusion as well as we have it now. And a lot of the guidelines, so even the recent ACS updated guidelines in 2025 still make the recommendation of within 24 hours post-MI, every patient should have a beta blocker on board, even oral or IV, however, they can get it, as long as they're clinically stable, not in cardiogenic shock, any other contraindications to being able to tolerate beta blockade. And that's mainly driven based on historical data, saying in patients, specifically in STEMI patients, there's not as much data, surprisingly, and the guidelines recognize this that there's not a lot of data within STEMI patient population. A majority of the information is from STEMI patients. And so they found that when patients coming in with STEMI, again, before all our historical improvements in reperfusion, they found that the addition of beta blockade helped with increasing myocardial energy efficiency. It also helped reverse the remodeling that we see. We know post-MI, your heart takes a major hit and your heart tries to almost kind of outsmart and kind of rewire itself. And so the beta blockade essentially helps to reroute that remodeling and hopefully reverse those effects. We find that it also helps decrease the heart rate as we would expect, and then it improve increases the ejection fraction mainly in those patients that take a major reduction in their ejection fraction post-MI. And as a result of this, because we're increasing EF, hopefully preventing long-term complications, we found that it decreases mortality and decreases hospitalizations. And one of the strong emphasis of the beta blockade therapy in post-MI patients is not only the cardiac remodeling, but it's also reversing this upregulation sympathetic stimulation that we see with patients that ultimately really solidified the use of beta blockade in our post-MI patients.

Speaker 3 5:13

Okay, so to summarize, you called out a few very important points, I think. And uh one thing you called out that stuck out to me is the fact that a lot of the data we have, which is great, we have a lot of data, as you said, with beta blockers, but a lot of it is pre earlier, earlier, decades ago. So before we had more modern interventions, as you say, reperfusion, these sorts of things that can impact outcomes, as well as um, you know, that pathophysiological benefit of beta blockers in terms of reducing that cardiac remodeling and and um uh the effect on the sympathetic nervous system. So there's that's the physiological effect, but then that has to be considered in context with the newer sort of interventions we have. Is that a fair summary?

Speaker 5:58

Absolutely. And I think too, we now have people are able to get reperfused more efficiently and more effectively. And we have more potent P2I12 inhibitors from antiplatelet agent management. So I think it's weighing overall management has improved with these STEMI post-MI patients that ultimately it makes it kind of difficult to actually equally assess old trials and new trials because you're thinking you're effectively fixing the problem more efficiently. And hopefully that will help prevent long-term outcomes. So it makes it to where maybe the role of beta blockade isn't as profound as we thought it was, and really improving reperfusion strategies maybe is your actual better option.

Speaker 3 6:45

Right. Okay, so that's sort of the crux of the the discussion, I think, that we we're not in the same time we were 40 years ago when we didn't have these newer interventions, and maybe the intervention of beta blockers is not pulling its weight as much as some of the other things that we're doing. Um you also highlighted the fact of the ejection fraction and considerations with that. So I'm sure we'll get into that a little bit more in a bit when we talk about the evidence. But um, the other thing that you called out too is the the guidelines. So current guidelines, they still do recommend beta blockers post a my, but I don't think they comment on a duration. Is that right? Or okay, I'm seeing Taylor not shaking her head, but go ahead, Ana.

Speaker 7:26

Yeah, so the current ACS guidelines actually do not have a very specific duration spelled out, and they even leave some ambiguity of the ejection fraction. So there's no guidance to say which ejection fraction you have to use beta blockers or which you don't have to use beta blockers. And now that even in the heart failure guidelines, we have all these varying scales of ejection fraction now. So you have heart failure reduced ejection, you have moderately reduced, you have preserved, and then you even have heart failure with recovery. And so now there's just a spectrum of ejection fraction, which unfortunately the guidelines really leave it more to, I think, clinician discretion. And we'll kind of talk through what those situations look like. But the guidelines currently, the recommendation is a class 1A recommendation of beta blockade within 24 hours. And then, like you said, there is no specific duration. They do acknowledge that there is no recommendation of duration. And then they recogni they also recognize that the ejection fraction, there's not a lot of data in the preserved ejection fraction, but there's more so in the reduced ejection fraction. But they won't say that you can't use beta blockade.

Speaker 3 8:46

Okay. And that again is going to tie into, I think, this pro-con discussion as well, quite a bit. Um, but when we think about those patients with reduced ejection fraction, um, those are our typical, what I typically think of as a classic heart failure patient. And we know beta blockers are a standard of care for those patients as well. So that's why that sort of ties into this discussion, those patients with reduced ejection fraction and the benefit there, regardless of the post-MI status. So great, great overview and getting the getting the groundwork laid there.

Why The Question Is Back

Speaker 3 9:13

Taylor, let's let's go to you for a moment and just sort of um give a high-level overview of why these questions are coming up now. We're gonna dig into the evidence a little bit more in that pro-con debate, but what's what's sort of changing? I think that the Anna highlighted we have these newer uh interventions, the reperfusion considerations that is probably coming into play. But what else is sort of driving these questions?

Speaker 1 9:35

Yeah, absolutely. I think now we are seeing that like now that we've had so much of this like gray area, we're starting to raise more of these questions. Oh, it's like, okay, well, what about our patients with more of a preserved injection fraction or our patients that don't fit our typical like um reduced injection fraction criteria for a heart failure and patients that maybe we look at stopping data blockers after a year or different durations because the guidelines don't speak to duration specifically. So, since we don't have clear answers for some of these questions, there's been a lot more data like looking at these areas in particular. And so we've had new trials within the last like a year or so that have looked at patients with more preserved ejection fractions to see what kind of benefits or not that we found from those trials. And that's kind of what's sparking this question. But also as we've seen the changes in like reperfusion techniques and the medications that we have available in general, we're starting to kind of reframe that question of like what are the things that we need to prioritize? And are beta blockers one of those things, or maybe are they not? And then, like, when we look at the comparison between like our like reduced ejection fraction, heart failure patients, the path with this there is something that is kind of you know undisputable, undisputable for the like chronic um reduction in the sympathetic nervous system and things that for the cardiac remodeling. We've seen the data for that we can't really um have that conversation of for saying there's not a role there because we know that there is, but that is so much more of an acute picture for our like in my patients and in that acute setting that maybe things are different from pathophysic standpoint as well, where we're seeing a different and then difference in benefits from our beta blocker use. And so the recent trials that have come out have really kind of opened that door more so of our as far as like having that conversation and having the purpose of this debate today.

Speaker 3 11:27

Excellent. Well, again, you both laid the groundwork so well. And um let's just dive right into it. I'm very interested to hear what you each have to say and your perspective. Um so it sounds like, you know, overall, to summarize that the the treatment strategies we have post-MI have changed. And so the question of additional benefit for beta blockers, especially in certain patients without reduced ejection fraction, might be changing a little bit. And so let's start with you, Anna, and hear your side first.

The Pro Case For Continuing

Speaker 3 11:53

Um, you're on the pro side. So, why and when do you think beta blockers should be used post-MI routinely?

Speaker 12:01

Yeah, I think it's definitely a great question. And as a cardiology pharmacist, we often get this question all the time. And I am always on the side of the overwhelming amount of benefits outweigh the risk, in my opinion. Um, and I think from the standpoint of from a MI picture, it's often not just an isolated incident. And so a lot of these patients have other risk factors and they're at further risk of further developing heart failure later down the line. So, from the standpoint of we kind of reviewed the clinical benefits, pathophysiologic. And when we think through the use of beta blockade, historically, it was every single patient got a beta blocker post-I, it was the CMS core bundle. Everyone, every hospital was critiqued on it. It how it was how you got reimbursed, all the guidelines really emphasize it. Um, and there hasn't really actually been any negative data to come out to say beta blockers are actually harmful. It's really just that maybe there's not as much benefit as we thought they were in the past. So, from the standpoint of kind of my pro side, is that for all of our post-MI patients with newly reduced or change in ejection fraction, the benefit of beta blockade in that cardiac remodeling and hopefully preventing the progression of further reduction in the ejection fraction or developing heart failure symptoms is overwhelmingly swings towards the benefit of beta blockade use. And so specifically when we think about our heart failure-reduced ejection fraction, we have the most amount of data with our beta blockade, including mitoprolol, bisoprolol, and then even um curvatolol as well, are in the heart failure guidelines from that standpoint of at least starting GDMT early. And we know that starting GDMT hopefully helps prevent that progression of further rejection in their ejection fraction. And so this has been.

Speaker 3 14:07

And probate alone and bisopral are the three we're thinking about, because that's often a question to succinate versus territrate and metoparol succinate. So just wanted to clarify that. And sorry to throw you off, but um I I love that you're tying in this GDMT concept because that was what Taylor was alluding to also. And when you think about all the other meds these patients are getting as part of that now, that that ties into Taylor's side a little bit too. So anyway, um, sorry to interrupt, please go ahead.

Speaker 14:30

Yeah, absolutely. Um, and so there has been a large amount of studies, specifically with those beta blockers that we mentioned, that show the reduction in mortality, reduction in hospitalization. And these were specifically in patients with a reduced ejection fraction. So an EF less than 40%, and they found a reduction in mortality and hospitalization when these agents were used post-MI with a reduced ejection fraction. Um, so kind of just throwing some names out because you'll see in the guidelines mentioned as well. So there was the Copernicus, there was a mitoprolol controlled release and Excel. So that's kind of covering the succinate formulation. They also did a curvatolol versus mitoprolol and actually found that curvatolol had better benefits over mitoprolol. However, there's critiques of the study, so it hasn't really changed practice of everyone has to get curvatolol. And then they even did a study of nebivalol, which isn't mentioned in the guidelines, but they found that in the seniors trial, nabivolol even had benefits. So it really solidifies that it is a class-wide effect that we would have benefit of this cardiac remodeling overall. And I think a majority of the beta blockade use is mainly the benefit is in those heart failure-reduced ejection fraction patients. And the theory is that maybe those HEFREF patients is kind of how I'll call them now, is that potentially they have more benefit in beta blockade because they have more systolic dysfunction. And their systolic dysfunction is being improved by the beta blockade. Whereas when we think about the HEF PEF patient population, the actual role of GDMT isn't as solidified when we think about compared to our HEF REF patients. Now, whether that's because of data, it's a little unclear. But a lot of the times our HEF PEF patients, unfortunately, from a GDMT perspective, we actually don't have the four-pillar GDMT. We actually only recently have SGLT2s, are actually the class 1A recommendation almost. And then you have MRAs or mineral cortipoid receptor antagonists, and beta blockade actually isn't in a HEF PEF picture when we think about patients who don't have an MI picture with HPEF. So it is a little bit more of a gray area, I'll even say from the pro side of where the heart failure-preserved ejection fraction comes in. And then we now have different labeling of our ejection fraction. And so now you even have them mildly reduced. So it's even more of a gray area of patients who don't have a HEF, you know, HEF ref picture, but they have an EF that's between 40 and 50. And so you say, how do we treat those patients? Because we know they're at high risk of potentially having further reduction in their ejection fraction, and it's especially thinking about what was their ejection fraction going into this MI event. And so they actually had a study, they had, I'm going to probably not pronounce it correctly, but it's the BATMI Dan Block trial, which actually specifically looked at patients who had an EF of at least 40% post-MI, and they actually found that patients had an overall reduction in the primary composite endpoint, which I don't always like composite endpoints, because there's always tactical kind of driving it. Driving it, yes. So you're thinking from a post-MI period, they're at highest risk of complications. So the benefit of beta blockade in the immediate post-MI period is actually beneficial across a variety of uh heart functions. When you really think about the overall clinical benefit. However, I think the continued use is where there's a lot of gray area and where that benefit really maybe no longer applies.

Speaker 3 18:36

I don't know if you can speak a little bit to the longer term data from a pro perspective, because like you said, I do think that is you elucidated very well how how the immediate acute phase, there there's seems like the pretty clear benefit. Um, but for that indefinite use host am I, what does that data look like generally?

Speaker 18:58

Well, I will say that because it's now part of the pillars of GDMT, I think there's more data from a hef ref picture. And as Taylor kind of alluded to, there's more data coming out of longer-term use. I will say it depends on your scope of long-term. Um because now we have patients living longer. And so do you say it's a three-year follow-up, or how long do we think is the progression of cardiac remodeling? So I think there is a large gray area of the duration where in our HEF-ref picture, we know, okay, they're at least starting on that beta blockade pillar of GDMT. And then we know the long-term benefits of that from a heart failure with reduced ejection fraction picture. But I think there's really a gray area now because HEF PEF is relatively newer. And so we really don't have the long-term durations to say, oh, when does the benefit kind of actually fall off in those um reserved? So even the guidelines acknowledge that there's really no duration that's recommended. So arguably, if you had a heart failure with a reduced ejection fraction patient who could no longer tolerate a beta blockade, we actually don't know if there's benefit of even continuing to try, even though we know some dose is better than no dose in the heart failure, reduced ejection fraction picture. But the duration is really unclear of do we do it one year after, do we do it three years after? Can we stop it 10 years after? There's a lot of gray area with the duration.

Speaker 3 20:33

Okay. So thank you, Anna, for summarizing that so well. The considerations, key considerations that came out to me are the uh ejection fraction and the the variation between, as you said, have pef, the hef mref and hef ref, those three. And those are sort of different categories of risk that you might be thinking about when when considering beta blocker use. And you know, to that point, how many beta block, how many patients, sorry, who are post-MI do we know how many patients post MI do have reduced ejection fraction? Is that the majority of patients? Not a hard number per se, but would you say that's most patients post MI have F ref?

Speaker 21:14

I think it's hard to capture sometimes when we think about a post-MI picture, usually an immediate echo afterwards actually is going to be understandably temporarily reduced. And so I think sometimes it's also reassessing and saying, do you have myocardial? So I think it's hard to pinpoint exactly how many people have a newly reduced ejection fraction. And it's also hard to capture if a lot of times, unfortunately, patients presenting with an ACS or MI picture, this might be their first point of contact with medical providers. And so were you sitting at a reduced ejection fraction for a while and then you had an MI, and then it that was kind of the straw that broke the camel's back and pushed you from the moderately reduced to the reduced. So it's really hard for me to exactly pinpoint the amount of percentage of patients just because we do have a large unknown. It's not uncommon for patients immediately post-MI with the myocardial damage to see a periphery reaction and ejection fraction. And then usually there's re-imaging, so a repeat echo in a month, three months to kind of reassess and see where they're true. And I think that would be a better picture of where definitely fraction is.

Speaker 3 22:28

Okay. Okay. That's a good call out to be thinking about that follow-up, as you said before, and reassessing that and uh understanding their ejection fraction in those later follow-ups. That's a great call

The Con Case And New Trials

Speaker 3 22:38

out. All right, so Taylor, uh Anna had her say, and now it's time for you. So um uh what do you think about Anna's perspective? Why do you think that beta blockers should not be used routinely post a MI?

Speaker 1 22:51

Yeah, and I think that is something to kind of like frame, I guess, my side for the con perspective, is that I think to Anna's point, our patients with like hef ref are again, the data there is like indisputable. So I'm not necessarily saying that for all of our patients, we need to reframe whether the question of beta blockers can be posed or not. I think it is particularly in those um subpopulations of our patients with like preserved ejection fractions, and then our patients who um kind of see more of that recovery, like post-MI is where most of this data is coming from, and where we're not really calling into question again from the HEFREF patients. But I think what is so interesting is there was like the meta-analysis that was performed recently, I think it was November of 25, that was like five person and colleagues that looked at like five key trials, and just to name those is the capital RCT, the reduced AMI, the reboot, the beta MI and Van Block trial, and then the smart decision trial, which were all looking at beta blockers and no but no beta blockers like after MI and being able to look at those from a more of a preserved ejection fraction standpoint. There were a couple of the trials that looked at those that were including up to like 40% or greater than 40% of an injection fraction. So it gets a little bit different as far as like which trials included which exact patient populations, but for the most part, they included those specific beta blockers that we think about the most. So metoprolol, carbatol, and bisoprolol. And then their overall endpoints were again pretty similar as far as like the composite from like overall death, having another like myocardial infarction or like heart failure after MI. And so out of all of those composite outcomes for most of the trials, there was no significant benefit that was found from like having beta blocker therapy on board for those patients. And so kind of what poses the con side is what also Anna kind of mentioned is maybe we're not seeing as much of a benefit here as we originally thought. And so is this just another medication that we're having our patients take that from, you know, we can go into that side of the con argument as well, related to polypharmacy and having a lot of medications for our patients to have to worry about, but also the beta blockers are not benign. You know, we have side effects and things to be aware of as well. And so whether it is our more like mild side effects related to just like the overall fatigue the patients may feel, or sexual dysfunction or depression, things like that that happen a little bit less commonly in actual clinical practice, it is something that our beta blockers in general are the most likely to kind of precipitate someone into kind of like an acute decompensated heart failure event or cardiogenic shock. And so if we're doing them kind of in a more aggressive way in times, or if something happens that changes with the patient's status, then we could precipitate some of those events with these patients. And so something that we have to consider with like the risks that are involved from using these medications as well, and then just seeing it from an outpatient standpoint, they're often not well tolerated because they just make patients feel a little bit worse than some of our other agents at times. And so we're often not able to uptrate them to the target doses that we would think about, like from a heart failure standpoint, or make many adjustments with them, where we're often having conversations about having to reduce the doses of the beta blockers or to stop them altogether. Um so it's something that is really driven by like patient tolerability, but also with this question of duration, we are looking at whether this is something that needs to be on for long term or whether it's six months or a year. And then that's kind of like the maximum amount of benefit that we would see in a post-MI like acute phase. And then after that, we could reevaluate because from an inpatient standpoint, we often see patients who would come in on like a beta blocker as a whole med. And in their history, like there's no documented like AFib or arrhythmia, they're not on it from like an uncontrolled hypertension standpoint, and all we can see is that they had like an MI 12 years ago. And you know, it doesn't seem like there's like a clear indication for a beta blocker now in current state, and maybe there's something that we're worried about how many medications the patient's taking or their overall mental status and remembering to take their medications. And so it's like at that point, can we now reevaluate whether leaving the beta blocker on board is like the most appropriate choice for them? So I think that is kind of where posing these questions is coming into play now.

Speaker 3 27:23

Yeah, and and so you you highlighted a few key downsides uh with the the con argument and thinking about why we might not consider routine use for all patients post on my tolerability question, polypharmacy question, questions about lack of benefit potentially in particularly in those patients without reduced ejector fraction and some of that meta-analysis you referenced, I think is a driving a lot of these newer questions as well and raising important questions for us to be reevaluating patients. And then also you mentioned the duration, which we talked about before and how that comes into play, because as you say, is six months one year versus five years, 12 years as your example. Yeah, yeah, we start to that starts to become a little bit fuzzier in terms of clear benefit.

Deprescribing Without Losing The Patient

Speaker 3 28:11

So in terms of I'm I'm thinking ahead a little bit, but in terms of patients who are like your case with the 12-year post to my patient, would you what what are considerations with de-prescribing? Are there downsides or concerns with de-prescribing? I mean, you talked about not being able to titrate up in some cases for patients who may benefit, but what about that other side of the coin?

Speaker 1 28:36

Yeah, I mean, I think from a de-prescribing standpoint, you know, we definitely have to kind of to Anna's point earlier, look at like overall other risk factors because there could be other risk factors that could uh predispose someone to having eventually the progression of like heart failure or heart failure with reduced ejection fraction. And there are things that we would be a little bit more concerned about leaving the beta blocker on board. I think that is a key thing to note with these trials is that if patients had other indications like AFib or uncontrolled hypertension, those indications were actually like those patients were excluded. So for our patients that have a little bit more of complexity to them as like other comorbidities and other indications for having beta blockers on board, we don't really have the data, I guess, from the trials that we've seen that say that beta blockers don't have a clear role and benefit in those um patients like cumulatively for all of those disease states.

Speaker 3 29:32

Okay.

Speaker 1 29:32

Um so it is something to consider because I will say also at our institution, we see probably the more complex patients than the more straightforward cases. Of course, yeah. And so thinking about that from like the trial perspective, you know, as far as like the things that they included or excluded and the patients that they've um seen, because they were more like European and like Asian-based trials as well. But from a deep prescribing standpoint, the I think one of the key things to think about as a pharmacist is like the patient preferences and the patient's buy-in. And if this is something that like the patient has really said, like this is impacting my quality of life, like I feel so terrible. And like I think that it is like potentially related to the beta blockers, like I felt better before this or whatever. Maybe, then like maybe if we trial it and they are feeling significantly better and less fatigued after, then having the patient buy-in is gonna be most impactful for feeling like they are heard and they're able to continue with their care versus patients that we kind of pose this conversation of the risks and benefits, and we say, Well, you know, we think we have more data to support potentially peeling this off now if you're open to it. And if they're like, no, no, no, like I still think that this is what I need to be on because we've had this conversation and this is what happened 12 years ago 12 years ago, then I think respecting those preferences and having the patient feel like they are having an active role in their care is what's most important.

Speaker 3 30:55

Sure. Yeah. And uh the reason I thought about deprescribing in the context of your con argument is because if it if it if it pose chal poses challenges to deprescriber, it's clinically difficult. You know, that's another consideration that might weigh against your argument. But um I think you you laid out the the evidence and and where we are in terms of why this question is coming up and and what why we might not think about using beta blockers routinely post a my in all patients. Anna, now that Taylor has shared her view, do you have any thoughts or responses to her sort of summary and where we where we might come to bottom line with both of those considerations?

Speaker 31:34

Yeah, I think it's definitely a hot topic. And I I can see definitely, I have to argue both sides at that point, um, which makes it even more challenging. Cause it really is, I think it comes down to very very patient-specific. Kind of my critique of the recent literature that's come out is that we don't have enough time. And so it's really thinking about now we look at heart failure as more of a progression and it's more metabolically derived than I think we thought before. And so now that if we have trials coming out saying, okay, at three years there's no benefit, okay, but what about in, you know, five years, 10 years? Is there potentially, if we were to compare patients, I almost wish there was a trial and I don't know how they would do it, but where you essentially had two different groups of people and you said, okay, these people got beta blockade for one month post-MI. They were all relatively maybe on the younger side, maybe in the 30 to 50 range. So uncharacteristic to have an MI in that kind of patient population. But I would be curious how those patients did with longer-term beta blockade use to hopefully prevent the further remodeling and restructuring of their heart. And I think sometimes that's where kind of my hesitation is of it's always hard to change your thought process of. I know going through pharmacy school, it was like everyone post-MI, post-cabbage, post-SCI, everyone gets beta blocker. It doesn't matter. It's kind of a knee-jerk reaction. And I think it's always good to be able to tailor it to the patient and say, okay, based on other clinical considerations happening with the patient and what their overall risk of further development of heart failure or worsening of heart failure, I think it allows us to really weigh where do we use beta blocker therapy? And I think in the immediate post-MI period, we have the most data to say yes, it's beneficial just from a complications management spec perspective. And I do kind of just have some hesitancy on the short-term follow-up for the newer studies that have come out, because I think most of them were about three years of follow-up, which is still a pretty decent follow-up. Um, and all the studies, again, more so confirm that there's maybe not as much benefit, but there's no harm. So there was no difference in overall side effects reported or re-hospitalizations or anything that would indicate that beta blockade was harmful in these pen in these patients. I kind of think of beta blocker therapy as kind of how we were revisiting aspirin for like primary prevention, where we always put everyone got aspirin, hopefully prevent something. And then we found out, oh, these patients actually are bleeding more. And so it reported more harm. Whereas now the newer beta blockade therapy trials are showing there's maybe just no benefit. Um, and so I think it's kind of maybe you have that discussion with the patient and saying, Do you feel it's uh helping you? Do you feel any different? And kind of reassessing and saying, well, we can start it and then kind of reassess it later, I think is the ultimate approach. Um hopefully not keeping them on uh beta blocking unnecessarily if there's really actually no benefit.

Speaker 3 34:48

So I I think you really called out the fact that the the duration is is the big, big question. And and that's where we are lacking long-term data. So that will be interesting to continue to see how uh how this evolves as we continue to um maybe pull back on beta block reuse postum I in some of these patients. Um and also the lack of harm is a really good call out there because uh Taylor, you were talking about tolerability considerations, patient side effects. That's a very individualized patient discussion that wasn't necessarily something Anna that you highlighted was seen in in the data. So it's not that we have this overwhelming concern about harm. It's more of a patient-specific consideration around harm. And so I think that that transitions well into sort of thinking about what we do with all of what you shared now in practice and how do we sort of translate this?

Practical Decision Points For Pharmacists

Speaker 3 35:36

A lot of it sounds like it's coming down to identifying which patients may or may not be good candidates. And so maybe like bullets of what you what you're thinking about when you have a patient in front of you. And let's not talk about that acute post-MI phase, but maybe longer, longer term and some follow-up. What are those questions going through your mind in terms of thinking when should this beta blocker be continued or not? Maybe let's start from that perspective versus the initiation perspective. Let's assume they're on it. And if you're thinking about backing off, what are the things that come to mind?

Speaker 1 36:12

Yeah, I guess just to kind of start, I think um some of the things as far as what kind of is more indicative of continuing it, you know, is for patients who, again, are tolerating it well, whether we consider that of them not having no like reported symptoms, no, you know, overwhelming like fatigue or shortness of breath that's worse than as we've continued their therapy or like fluid accumulation, things that would make us more concerned from like tipping over into more of a cardiogenic shock picture. Patients that are filling their prescriptions regularly, that are going to their cardiology or their PCP follow-ups, and that we're seeing that they're actually plugged in from like an outpatient standpoint and they're really bought into their care. So they are like having those conversations with their physicians as well as something that I think is more indicative of being able to continue therapy versus our patients that if like insurance or cost or like polypharmacy are already concerned, then I think we could have that conversation of maybe we haven't seen like robust like harm from them, but with the lack of like clear benefit in like beta blockers, post MI with our preserved EF patients, maybe then we can have that conversation about removing that agent for them and we can focus our efforts on maintaining other medications that are crucial, like post-MI or for their other concomitant disease states or comorbidities. Because that's a very real part of what we deal with as pharmacists too, is that we have to kind of triage what patients have access to, whether it's from self-pay or insurance or whatever it may be. And like if they're able to kind of remember to take a handful of medications, but as soon as we are saying closer to 10 medications, then that's kind of harder for them to manage and navigate at home. So maybe for those patients, we can have that conversation of peeling those off and discontinuing, as well as if there are patients who maybe do not have like a real clear support system at home or are often confused with their medications. We've seen something like potentially a beta blocker kind of precipitating them more into like acute um decompensated heart failure for exacerbations for like um hospitalization, that they are not clear on how they should be taking it appropriately. And so we could, from a tolerability standpoint, see those events precipitated. It's very patient-specific, but I think those are kind of the first things that I think of.

Speaker 3 38:34

Patient-specific, and you alluded to previously the shared decision-making concept and working through that with the patient, their preferences, their goals, and taking all that into consideration. And is there anything you want to add to what Taylor shared?

Speaker 38:48

Yeah, and I think definitely a good call out of the kind of being plugged into care. I think a lot of the times the issue that arises is okay, if I de-prescribe something, we kind of have to have a follow-up to say, oh, we can't just, you know, set it and forget it, but we also can't just take it away and then never follow up. Um, and so I think with the deprescribing, it can be that multidisciplinary discussion between the patient and saying, okay, your X number of months or year out from your MI, we have a recent echo, your EF looks great, your numbers look great, your other conditions are well controlled, you started diet, you know, exercise modifications, you're controlling your blood pressure, you're controlling your diabetes, all these other risk factors that we know contribute to the development of heart failure. I think it's reasonable to say, hey, let's revisit taking you off the beta blocker and then have a follow-up to see how everything's going. And I think sometimes that follow-up is what happens in the falling through the cracks. I think that's an area as pharmacists oftentimes were the ones in the inpatient side and even outpatient side, where we're able to have that conversation with the provider and really advocate for the patient, where if the patient's coming in complaining of tolerability issues with the beta blocker, we're able to say, hey, maybe it's actually not benefiting them based on their gesture fractions this, their X number of months, years out of their MI, and being able to really advocate for the patient and then having more close follow-up to really assess, oh, maybe we do need to restart it back and see if we trial a different beta blocker. I think in the past it was really hard to argue for deprescribing because there was so much overwhelming evidence of benefit of saying, okay, you reduce hospitalizations. But now we have data to say, well, maybe there's actually not as much benefit in certain patient populations, um, specifically the preserved ejection fraction. Right. Um, I think it it at least is worth having that conversation of. And it's very patient-specific. I think it makes it where the gray area is very difficult because you can't make a blanket statement of every even every HEF PEF patient or every Hef Meref patient benefits or doesn't benefit from beta blocker because we know that it's not an isolated uh picture. And that it's multiple things feeding into one another. And so I think it's having that close follow-up and at least surveillance, whether it be, you know, telehealth visits, see if their symptoms are worsening, things along those lines. Um, which kind of puts more burden potentially on the healthcare team as a whole. Um, but then you're also hopefully preventing further complications as well. So I think it's kind of a double-edged sword in a way.

Speaker 3 41:38

Yeah, yeah. Please, Taylor.

Speaker 1 41:41

Sorry, I was just gonna mention because like I think it's also like interesting to see like the patients are listening and they're buying in. Like I thought about there was a patient in clinic, we were in internal medicine clinic in September, and one of these trials had just recently been published, and it was like in the news as far as like, oh, maybe not all patients like post um MI need to be on a beta blocker. And I actually had like an older uh female patient that asked me about it in clinic one day, and she was like, you know, they're saying that maybe we don't need to like stay on this forever. Like, can I come off of mine? Like, do I need to stay on my beta blocker? And it was just like one or two trials at that point, and like, you know, the guidelines had just um been republished where it wasn't like a guideline standpoint for us to say that we were kind of revisiting that. And so that was a conversation that I had with her that day as far as you know, we have a little bit of data to look at this, but not a robust amount just yet, and we're looking at it more, and the guidelines haven't taken a clear stance on that. So it's definitely a conversation that we can have, and I'm glad that you brought it up and you're listening, you're buying into your care, and definitely something to have more of a conversation with your cardiologist, but it was it wasn't something that I felt like was clear enough at the time. Maybe we have a little bit more data now at the current day. But I think just seeing that patients are trying to learn more about what's going on, like with their disease sites, and like be more informed was really exciting to see as well.

Speaker 3 43:08

Yeah, absolutely. And I think you know, it'll be interesting to see if the guidelines catch up with the evidence and how long that might take. And that's something we just need to keep watching and and staying on top of. But I I think that what I'm taking away from this discussion, and again, my background is community pharmacy. So uh when I would be doing a med review, for example, if if you see a beta blocker on board, uh trying to identify the indication, and obviously that's much more difficult in some settings than others, but trying to dig a little deeper and identify it. Do they have half ref, or do it was it just started post demi, or what is the indication that we're thinking about here? Because I think the biggest takeaway from the discussion for me is it's worth having the conversation. And then you can work with the patient, individualize that care, use that shared decision making, but the beta blocker can be a cue to have the conversation and to dig into that gray spot a little bit more.

Speaker 44:00

Yeah, absolutely. And I think too, it's maybe trying to tease out, which I think is always hard to find that ideal patient that is just has an MI and like no, of course.

Speaker 3 44:11

Yeah, right.

Speaker 44:12

Hard to tease that out because Taylor had a great point of this newer data is really just an isolated post-MI patients with a preserved or at least an EF above 40% in most of the studies, if not above 50%, and that they didn't have other indications for beta blockade. So it's very hard to find those isolated patients who don't have other underlying arrhythmias, tachycardias, things along those lines. And then also, even if you're kind of old school and using it to help with some of the blood pressure effects and things along those lines, it's really hard to find a patient that already doesn't have those complications. So it's really honestly hard to find those perfect evidence that would fit kind of how they enrolled the studies.

Speaker 3 44:56

Yeah, absolutely. And that's where my question earlier about how many of these patients post a my have hef ref, because I in my mind it is probably a lot. And as you say, there's all kinds of other comorbidities and considerations with these patients too. So it's definitely not a clear-cut answer from that perspective. And like you say, trying to find that perfect patient where they fit those enrollment criteria, that's maybe not what you're looking for. But um again, still a good opportunity to have that conversation and start this discussion.

Game Changer Takeaways And CE

Speaker 3 45:23

So fantastic debate. I loved hearing both sides, and I really feel like we had a good collegial discussion and sort of came down to the pros and cons of those um of beta blocker therapy post-MI. And just to wrap up with our game changer, it does our game changers podcast. So, uh Taylor, would you like to share what is the game changer that you want our listeners to walk away with today?

Speaker 1 45:44

Yeah, I think our game changer from today would just be again to have that conversation with new evidence coming out to look at beta blockers post-MI for some of our patients. It may not be as clear-cut as we thought, where we just leave the beta blocker on indefinitely. And so I think when those patients come across being able to recognize and have that conversation, and that's a multidisciplinary conversation and like with collaborative with the patient as well. So with your physicians, with your mid-level practitioners, like everyone that's involved in the care for this patient, having that conversation of like, here's the data, here's what we have for this patient that's in front of us, and here are the patient's preferences and like starting that conversation of do we continue for this patient, or is this someone that we can look at not continuing and being able to have that discussion, which it hasn't really become a discussion until now. So just opening that for the conversation.

Speaker 3 46:37

Yeah. And like I said, continuing to stay on top of what's coming out because I will be interested to see when future guidelines are published, how how that might evolve. Anna, any closing thoughts for you?

Speaker 46:46

Yeah, no, I'm excited to see they they just had the ACS guidelines updated last year. So I don't know how long it might take for it to be in guidelines, but I hope that the next at least reiteration will even have even more trials and hopefully that gray area of the duration, and then maybe even which patients need it immediately versus hey, we can take it off um X number of years after an MI. I think would be great because we're always we're always on board for deprescribing whenever possible and making we have only the meds necessary is the goal.

Speaker 3 47:20

Absolutely. That's that's a key role that we play as pharmacists. I think you summed that up well. Thank you so much, Taylor and Anna, for your time. This is fantastic. And I think I took a lot away from this discussion. I know our listeners will too. So thank you so much for your time and expertise here.

Speaker 47:32

Thank you so much. Thank you.

Speaker 2 47:38

And that's it for this week. Be sure to log in to Healthmart University to claim your CE credit for this episode. As always, have a great week and keep learning. We'll talk to you next week.