The document discusses the effectiveness of beta blockers in acute coronary syndrome both with and without heart failure. It provides evidence that beta blockers reduce mortality, sudden cardiac death, recurrent heart attacks, and rehospitalization after a myocardial infarction. Specifically, beta blockers reduce the risk of adverse events by 20-30% when started within 24 hours of symptoms in patients without contraindications. The document concludes that beta blockers remain a cornerstone therapy for acute coronary syndrome, and their long-term use for 2-3 years is recommended after myocardial infarction for secondary prevention.

1. Chẹn Bêta Có Hiệu Quả Trong Hội Chứng Mạch
Vành Cấp Với Suy Tim hay Không Có Suy Tim?
Are there really effective of the beta blockers in acute coronary
syndrome with heart failure or without heart failure?
PGS. TS. BS. TRẦN VĂN HUY FACC FESC
Phó Chủ Tịch Phân Hội Tăng Huyết Áp Việt Nam
PCT Hội TMMT. Chủ Tịch Hội Tim Mạch Khánh Hòa

2. Risk Factors:
Diabetes
Hypertension
Vascular
Dysfunction
Vascular Disease
Tissue Injury
(MI, Stroke)
Pathological
Remodeling
Target Organ
Dysfunction (HF, Renal
iArrhythmia)‫‏‬
End-stage
Organ Failure
Death
Oxidative Stress /
Endothelial
Dysfunction
Target Organ
Damage
Adapted from Dzau et al. Circulation. 2006;114:2850-2870.
Chuổi Bệnh Lý Tim Mạch
MI: Myocardial infarction
HF: Heart failure
Sympathoadrenergic
System

3. A-II
Interactions Between RAAS and SNS
• Angiotensin II
– Central SNS activation
– Increased NE release
• Renal sympathetic
nerves
– Renin release: b1
– Vasoconstriction: a1
– Na/H20 retention: a1
– Vascular remodeling: a1
renin
SNS Activity
NE
SNS=sympathetic nervous system; NE=norepinephrine; A-II=angiotensin II.
Cody. Am J Cardiol. 1997;80:9J-14J.

4. VNM/NONCMCGM/0717/0020

5. Beta-blockers are considered a cornerstone of
therapy in patients with AMI
• Reduce heart rate, contractility, atrioventricular
(AV) conduction and ectopic activity.
• May increase perfusion of ischaemic areas by
prolonging the diastole and increasing vascular
resistance in non-ischaemic areas
• Reducing infarct size,
• Increasing threshold for ventricular arrhythmias,
and,
• Over the long term, preventing maladaptive
ventricular remodeling and HF.
Bonnemeier H . Am J Cardiol2000;85:815-20.
Ibanez B . Circulation2013;128:1495-503. Foody JM. JAMA 2002;287:883-9

8. –22% –20% –20%
Hanes DS et al. J Clin Hypertens (Greenwich). 2001;3(4):236-243.
Chẹn β Giảm Các Biến Cố Tim Mạch Sau
Nhồi Máu Cơ Tim
–30%
–40%
–20%
–10%
0%
–33%
Overall
mortality
Sudden
cardiac
death
Non-sudden
death Nonfatal MI
15 Trials (n =18,995)

9. Chen et al Lancet 2005;366:1622-32.

10. Chen et al Lancet 2005;366:1622-32.

11. Chen ZM et al Lancet 2005;366:1622-3

12. Chen ZM et al Lancet 2005;366:1622-32.

13. Clinical Outcomes With Beta-Blockers After MI
Outcomes
60 RCT; 102.003 pt
Pre-Reperfusion Era
RR (95% CI)
Reperfusion Era
RR (95% CI)
Cardiac Death 0.87 (0.78, 0.98) 1.00 (0.91, 1.09)
Sudden Death 0.77 (0.56, 1.05) 0.94 (0.86, 1.01)
MI 0.78 (0.62, 0.97) 0.72 (0.62, 0.83)
Angina Pectoris 0.88 (0.82, 0.95) 0.80 (0.65, 0.98)
Stroke 2.96 (0.47, 18.81) 1.09 (0.91, 1.30)
HF 1.06 (0.98, 1.16) 1.10 (1.05, 1.16)
Cardiogenic Shock 1.05 (0.89, 1.23) 1.29 (1.18, 1.40)
Drug Withdrawal 1.13 (1.02, 1.24) 1.64 (1.55, 1.73)
Bangalore S et al. Am J Med 2014;127:939-53

14. Liệu pháp BB & các biến cố TM ở BMV
mới chẩn đoán: Phân tích 26.973 BN
Andersson C, et al. J Am Coll Cardiol 2014;64:247–52.

15. 2013 ACCF/AHA Guideline for the Management of ST-
Elevation Myocardial Infarction
Beta Blockers
Oral beta blockers should be initiated in the first 24 hours in patients
with STEMI who do not have any of the following: signs of HF, evidence
of a low output state, increased risk for cardiogenic shock,* or other
contraindications to use of oral beta blockers (PR interval >0.24
seconds, second- or third-degree heart block, active asthma, or
reactive airways disease).
Beta blockers should be continued during and after hospitalization for
all patients with STEMI and with no contraindications to their use.
I IIa IIb III
I IIa IIb III
*Risk factors for cardiogenic shock (the greater the number of risk factors present, the higher the
risk of developing cardiogenic shock) are age >70 years, systolic BP <120 mm Hg, sinus tachycardia
>110 bpm or heart rate <60 bpm, and increased time since onset of symptoms of STEMI.

16. Patients with initial contraindications to the use of beta blockers in the
first 24 hours after STEMI should be reevaluated to determine their
subsequent eligibility.
It is reasonable to administer intravenous beta blockers at the time of
presentation to patients with STEMI and no contraindications to their
use who are hypertensive or have ongoing ischemia.
I IIa IIb III
I IIa IIb III
2013 ACCF/AHA Guideline for the Management of
ST-Elevation Myocardial Infarction
Beta Blockers

17. 2014 AHA/ACC Guideline for the Management of Patients
With Non–ST-Elevation Acute Coronary Syndromes
I IIa IIb III
Initiate oral beta-blockers within the first 24 hours in the
absence of HF, low-output state, risk for cardiogenic
shock, or other contraindications to beta-blockade.
I IIa IIb III
Use of sustained-release metoprolol succinate, carvedilol, or
bisoprolol is recommended for beta-blocker therapy with
concomitant ACS without ST-segment elevation, stabilized HF,
and reduced systolic function
It is reasonable to continue beta-blocker
therapy in patients with normal LV function
with ACS without ST-segment elevation.
I IIa IIb III

18. Early Intravenous Beta-Blockers in Patients With ST-
Segment Elevation Myocardial Infarction Before
Primary Percutaneous Coronary Intervention
EARLY-BAMI Investigators. J Am Coll Cardiol 2016;67:2705–15

19. b-Blockers & Mortality After AMI Without HF
Dondo TB. J Am Coll Cardiol 2017;69:2710-20.

20. Cumulative incidence of mortality among STEMI patients who
underwent PCI and were discharged alive with GRACE risk scores
<121 (A) and ≥121 (B)
Nakatani D J Thorac Dis 2017;9(10):3616-3619
Nhóm dùng BB có GRACE 121-141 giảm 56% TV so với không dùng P<0,001
Nakatani D, et al Am J Cardiol 2013;111:457-64

21. Effect of Beta-Blocker Dose on Survival After Acute
Myocardial Infarction (the OBTAIN study)
Jeffrey J et al J Am Coll Cardiol 2015;66:1431–41

22. BB Trong NMCT theo ESC 2017

23. MERIT-HF: b-Blockade improves
survival in CHF

24. MERIT-HF: b-Blockade improves
survival in post-MI patients with HF

25. MERIT-HF: Subgroup analysis in post-
MI patients with HF (LVEF <25%)

26. Coronary Heart Disease and BB:
Recommendations
Treatment
• In patients with prior myocardial infarction, β-blockers should be
continued for at least 2 years after the event. B (ADA 2018)
• Beta-blocker therapy should be started and continued for 3 years in
all patients with normal LV function who have had MI or ACS. I B
(AHA/ACCF Secondary Prevention 2011)
• It is reasonable to continue beta-blockers beyond 3 years as chronic
therapy in all patients with normal LV function who have had MI or
ACS. IIa B (AHA/ACCF Secondary Prevention 2011)
• In adults who have had a MI or acute coronary syndrome, it is
reasonable to continue GDMT, beta blockers beyond 3 years as
long-term therapy for hypertension. IIa B (ACC/AHA 2017)Cardiovascular Disease and Risk Management:
Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S86-S104

28. Kết Luận
• Chẹn bêta vẫn là thuốc nền tảng trong hội chứng
mạch vành cấp, tuy nhiên tùy thuộc điều trị có can
thiệp tái tưới máu hay không mà có hiệu qủa khác
nhau
• Sau NMCT cấp nếu không chống chỉ định, nguy cơ
choáng tim thấp, nguy cơ loạn nhịp cao cần xem
xét BB tĩnh mạch sau đó dùng uống, HA phải
>120mmHg, nhịp tim 60-110 l/p trước khi PCI I A
• Dùng BB uống (metoprolol succinat, bisoprolol,
carverdilol) thường quy sau NMCT cấp khi có suy
tim ổn định EF <40% , nếu không chống chỉ định I A

29. • Khi có Hội chứng Mạch Vành Cấp không có suy tim, BB
vẫn có chứng cứ giảm tử vong 56% khi chỉ số GRACE
121-141, giảm loạn nhịp, giảm NM và đau ngực tái
phát nên cần chỉ định thường quy trong thời gian nằm
viện và lâu dài từ 2-3 năm, II a
• Không được dùng BB tĩnh mạch trong NMCT khi HA
thấp <120mmHg, suy tim cấp Killip III, IV, Bloc AV II,III
nhịp chậm < 50l/p
• Liều BB thấp trong NMCTC không suy tim (12,5-25%
liều đích) chứng minh giảm tử vong sau NMCT cấp so
với không BB và hiệu quả hơn liều trung bình (>50%).

30. Photo: Huy Tran