Beta blockers for long-term management of acute coronary syndromes

Start a beta blocker during the hospital admission for acute coronary syndrome once the patient is haemodynamically stable, unless contraindicated. For patients with cardiogenic shock, acute heart failure, heart block or significant bradycardia, do not start beta-blocker therapy until these have resolved.

Following the acute coronary syndrome, the recommended duration of beta-blocker therapy varies. Much of the evidence for the benefit of beta-blocker therapy predates modern reperfusion therapy. Long-term beta-blocker therapy (beyond 12 months) is more likely to be beneficial in patients with ongoing ischaemia or left ventricular dysfunction. In patients with successful revascularisation, preserved left ventricular function and no angina, consider stopping beta-blocker therapy after 12 months (or earlier if the patient is experiencing adverse effects). See Beta blockers for secondary prevention of atherosclerotic cardiovascular events for more information.

The beta-blocker dosage required varies and is determined by the patient’s cardiologist. For haemodynamically stable patients, suitable regimens are:

Increase the beta-blocker dose as required to the maximum tolerated or target dose.

For patients with left ventricular dysfunction (left ventricular ejection fraction 40% or less), use one of the beta blockers recommended for heart failure (carvedilol, bisoprolol, nebivolol or metoprolol succinate) instead of atenolol or metoprolol tartrate. See Beta blockers for HFrEF for dosage.