Advertisement

Intravenous Beta Blocker Therapy for Acute Myocardial Infarction

  • Robin M. Norris
  • Michael A. Brown
Part of the Acute Coronary Care Updates book series (ACCU, volume 2)

Abstract

It has been known since 1959 (1) that blood levels of epinephrine and norepinephrine are raised after myocardial infarction and that the extent of the rise parallels the severity of infarction. Although it is likely that large infarcts cause high catecholamine levels rather than high catecholamine levels causing large infarcts, most cardiologists have thought that stimulation of the heart by epinephrine and norepinephrine must be harmful by increasing myocardial oxygen uptake or by causing life-threatening arrhythmias. When beta blockade with propranolol became available in the early 1960s and was shown to be effective for the treatment of angina pectoris, a number of trials were done comparing propranolol given orally in a dose of 10–20 mg 4 times daily with conventional treatment for acute myocardial infarction. Although initial results were conflicting, evidence suggested that hospital mortality and morbidity from infarction were not affected by oral administration of the beta blocker. By today’s standards, however, these trials were too small to avoid the Type 2 error, treatment was started too late for any beneficial effects on infarct size, and the first pass effect of hepatic metabolism (which prevents a therapeutic blood level being achieved after a first oral dose), was ignored. At this time, it was considered that intravenous administration of a beta blocker during developing infarction was potentially dangerous by causing excessive cardiac depression, so no trials using intravenous administration were attempted.

Keywords

Acute Myocardial Infarction Infarct Size Beta Blocker Beta Blockade Suspected Acute Myocardial Infarction 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Gazes PC, Richardson JA, Woods EF. Plasma Catecholamine concentrations in myocardial infarction and angina pectoris. Circulation 19: 657–661, 1959.PubMedGoogle Scholar
  2. 2.
    Maroko PR, Kjekshus JK, Sobel BE, Watanabe T, Covell JW, Ross J, Braunwald E. Factors affecting infarct size following experimental coronary artery occlusions. Circulation 43: 67–82, 1971.PubMedGoogle Scholar
  3. 3.
    Mueller HS, Ayres SM, Religa A, Evans RG. Propranolol in the treatment of acute myocardial infarction. Effect on myocardial oxygenation and hemodynamics. Circulation 49: 1078–1087, 1974.PubMedGoogle Scholar
  4. 4.
    Peter T, Norris RM, Clarke ED, Heng MK, Singh BN, Williams B, Howell DR, Ambler PK. Reduction of enzyme levels by propranolol after acute myocardial infarction. Circulation 57: 1091–1095, 1978.PubMedGoogle Scholar
  5. 5.
    Conway RS, Weiss HR. Role of propranolol in improvement between 02 supply and consumption in an ischemic region of the dog heart. J Clin Invest 70: 320–328, 1982.PubMedCrossRefGoogle Scholar
  6. 6.
    Mueller HS, Ayres SM. Metabolic response of the heart in acute myocardial infarction in man. Am J Cardiol 42: 363–371, 1978.PubMedCrossRefGoogle Scholar
  7. 7.
    Mueller HS, Ayres SM. Propranolol decreases sympathetic nervous activity reflected by plasma catecholamines during evolution of myocardial infarction in man. J Clin Invest 65: 338–345, 1980.PubMedCrossRefGoogle Scholar
  8. 8.
    Yusuf S, Peto R, Lewis J, Collins R, Sleight P. Beta blockade during and after myocardial infarction: An overview of the randomized trials. Progr Cardiovasc Dis 27: 335–371, 1985.CrossRefGoogle Scholar
  9. 9.
    Owensby DA, O’Rourke MF. Failure of pindolol to alter determinants of myocardial oxygen requirements, enzyme release or clinical course in acute myocardial infarction. Aust NZ J Med 15: 704–711, 1985.Google Scholar
  10. 10.
    Roberts R, Croft C, Gold HK, Hartwell TD, Jaffe AS, Muller JE, Mullin SM, Parker C, Passammani ER, Poole WK, Raabe DS, Rude RE, Stone PH, Turi ZG, Sobel BE, Willerson JT, Braunwald EB. Effect of propranolol on myocardial infarct size in a randomized blinded multicenter trial. N Engl J Med 311: 218–224, 1984.PubMedCrossRefGoogle Scholar
  11. 11.
    Norris RM. Beta blockers in acute myocardial infarction. Drugs 29: 97–104, 1985.PubMedCrossRefGoogle Scholar
  12. 12.
    Norris RM, Sammel NL, Clarke ED, Smith WM, Williams B. Protective effect of propranolol in acute myocardial infarction. Lancet 2: 907–909, 1978.PubMedCrossRefGoogle Scholar
  13. 13.
    Yusuf S, Sleight P, Rossi P, Ramsdale D, Peto R, Furze L, Sterry H, Pearson M. Motwani R, Parish S, Gray R, Bennett D, Bray C. Reduction in infarct size, arrhythmias and chest pain by early intravenous beta blockade in suspected acute myocardial infarction. Circulation 67 (Suppl I): 32–41, 1983.Google Scholar
  14. 14.
    The MIAMI Trial Research Group. Metoprolol in acute myocardial infarction (MIAMI). A randomised placebo-controlled international trial. Eur Heart J 6: 199–226, 1985.Google Scholar
  15. 15.
    Norris RM, Barnaby PF, Brown MA, Geary GG, Clarke ED, Logan RL, Sharpe DN. Prevention of ventricular fibrillation during acute myocardial infarction by intravenous propranolol. Lancet 2: 408–413, 1984.Google Scholar
  16. 16.
    First International Study of Infarct Survival Collaborative Group. A randomised trial of intravenous atenolol among 16,027 cases of suspected acute myocardial infarction: ISIS I. Lancet. In press.Google Scholar
  17. 17.
    Brown MA, Norris RM, Barnaby PF, Geary GG, Brandt PWT. Effect of early treatment with propranolol on left ventricular function four weeks after myocardial infarction. Br Heart J 54: 351–356, 1985.PubMedCrossRefGoogle Scholar
  18. 18.
    Ryden L, Arniego R, Amman K, Herlitz J, Hjalmarson A, Holmberg S, Reyes S, Smedgard P, Swedberg K, Vedin A, Waagstein F, Waldenstrom A, Wilhelmsson C, Wedel A, Yamamoto M. A double-blinded trial of metoprolol in acute myocardial infarction. Effect on ventricular tachyarrhythmias. N Engl J Med 308: 614–618, 1983.PubMedCrossRefGoogle Scholar
  19. 19.
    Paxton JW, Norris RM. Propranolol distribution after acute myocardial infarction. Clin Pharmacol Ther 36: 337–342, 1984.PubMedCrossRefGoogle Scholar
  20. 20.
    Mullane JF, Kaufman J, Dvornik D, Coelho J. Propranolol dosage, plasma concentration and beta blockade. Pharmacol Ther 32: 692–700, 1982.CrossRefGoogle Scholar

Copyright information

© Martinus Nijhoff Publishing, Boston 1987

Authors and Affiliations

  • Robin M. Norris
    • 1
  • Michael A. Brown
    • 1
  1. 1.Coronary Care UnitGreen Lane HospitalAuklandNew Zealand

Personalised recommendations