Thank you for this. Lesson 2 is so important for many quality metrics, not just BB therapy post MI. Lesson 4 was fascinating. I inherited many patients from retired providers who have been on beta blockade for their HTN for decades and I haven’t changed the meds because their BP in the office is good. Now I’m rethinking that and have the knowledge needed to explain why I should change to an ACE-I or ARB. Thanks!
Thanks for covering this. I’d stopped prescribing BB at discharge with anyone post MI, post revasc, with preserved LV fxn (ie EF>50), based on Reduce-AMI. As the trial was silent on EF 40-50, I had continued with BB use in those patients. Given the latest subgroup meta-analysis of Reboot, Betami-Danblock, and Capital RCT, I will continue with that practice pattern. As you also note, none of this should obscure the fact that BB remain foundational in anyone post MI with HF or EF<40….none of these trials apply to those patients. I would submit that those with incomplete revascularization and residual ischemic substrate post MI would also merit BB continuation, irrespective of EF.
For a detailed summary of the evidence for post MI BB to begin with (starting in the 1980s), the landmark studies are reviewed in detail on the Cardiology Trials substack (for which Dr. Mandrola is also a contributor). Those trials pre-date my training era and were “settled science” at the time which I did not question….but it was certainly an eye-opener to see those details with a 21st century lens. And that exercise definitely sustains your contention that evidence should have an expiration date….or at least should be re-examined periodically in the face of new evidence and/or evolution of practice patterns.
Shelf-life concept is a good one. The environment changes (patient profiles, healthcare interventions, etc), and the gold-standard RCT may no longer be applicable. I wonder how to prioritize looking at standard-of-care processes to see if they need to-be reevaluated.
PA here. In the CVICU I still see post-MI patients on beta blockers by default, even with normal EF and clean revascularization — like we’re treating the metric, not the patient.
These trials make it clear.. modern care has changed, and our habits (and quality measures) need to catch up.
I agree with your approach. I am a 77-year-old family physician, and I had hypertension in the past, but I managed to return to normal or even low blood pressure with lifestyle changes--healthy diet, exercise, good sleep, etc. I do take a low-dose beta-blocker on some days because I have intermittent atrial fibrillation, and at times my rate is a bit fast. I also chose not to take a blood thinner, as I am very active physically. Instead, I take high-dose omega-3, which has an antiplatelet effect. After more than 30 years of doing so, I continue to do well. As you say, individualize treatment!
Thank you for this. Lesson 2 is so important for many quality metrics, not just BB therapy post MI. Lesson 4 was fascinating. I inherited many patients from retired providers who have been on beta blockade for their HTN for decades and I haven’t changed the meds because their BP in the office is good. Now I’m rethinking that and have the knowledge needed to explain why I should change to an ACE-I or ARB. Thanks!
Thanks for covering this. I’d stopped prescribing BB at discharge with anyone post MI, post revasc, with preserved LV fxn (ie EF>50), based on Reduce-AMI. As the trial was silent on EF 40-50, I had continued with BB use in those patients. Given the latest subgroup meta-analysis of Reboot, Betami-Danblock, and Capital RCT, I will continue with that practice pattern. As you also note, none of this should obscure the fact that BB remain foundational in anyone post MI with HF or EF<40….none of these trials apply to those patients. I would submit that those with incomplete revascularization and residual ischemic substrate post MI would also merit BB continuation, irrespective of EF.
For a detailed summary of the evidence for post MI BB to begin with (starting in the 1980s), the landmark studies are reviewed in detail on the Cardiology Trials substack (for which Dr. Mandrola is also a contributor). Those trials pre-date my training era and were “settled science” at the time which I did not question….but it was certainly an eye-opener to see those details with a 21st century lens. And that exercise definitely sustains your contention that evidence should have an expiration date….or at least should be re-examined periodically in the face of new evidence and/or evolution of practice patterns.
Shelf-life concept is a good one. The environment changes (patient profiles, healthcare interventions, etc), and the gold-standard RCT may no longer be applicable. I wonder how to prioritize looking at standard-of-care processes to see if they need to-be reevaluated.
PA here. In the CVICU I still see post-MI patients on beta blockers by default, even with normal EF and clean revascularization — like we’re treating the metric, not the patient.
These trials make it clear.. modern care has changed, and our habits (and quality measures) need to catch up.
I agree with your approach. I am a 77-year-old family physician, and I had hypertension in the past, but I managed to return to normal or even low blood pressure with lifestyle changes--healthy diet, exercise, good sleep, etc. I do take a low-dose beta-blocker on some days because I have intermittent atrial fibrillation, and at times my rate is a bit fast. I also chose not to take a blood thinner, as I am very active physically. Instead, I take high-dose omega-3, which has an antiplatelet effect. After more than 30 years of doing so, I continue to do well. As you say, individualize treatment!