Should beta blockade be part of the ED protocol for patients with Acute Coronary Syndrome?

I’m pretty sure everyone agrees beta blockade has significant benefit on patients with heart disease.  However, when is the best time to give the beta blocker?  Within the first hour?  24 hours?  Month?  Should beta blockade be given intravenously?  or orally?

UpToDate’s summary recommends: “For all patients with acute MI, we recommend initiation of oral beta blockers within the first 24 hours, as long as no contraindications are present. (Grade 1B). ”

The 2013 ACCF/AHA STEMI Management Guidelines give a Class 1 recommendation to starting oral beta blockers within 24 hours of presentation, but a class 2a recommendation to give IV beta blockade at time of presentation to those “who are hypertensive and have ongoing ischemia.”  (

Please post your thoughts below by clicking on the “reply” button.


3 thoughts on “Should beta blockade be part of the ED protocol for patients with Acute Coronary Syndrome?

  1. During my training, I was taught that giving someone presenting with Acute Coronary Syndrome an IV beta blocker basically guarantees that they will go into cardiogenic shock. I don’t give IV beta blockers unless patients are profoundly hypertensive (usually SBP > 160’s). I will give IV beta blockers if the cardiology consultant requests that they be given, but I don’t usually even ask about this. I think I would be fine giving oral beta blockade in the ED, but it’s just not part of my normal ACS management routine at this time.
    However, I just came across this study suggesting that there is no increased incidence of cardiogenic shock, and that pre-PCI administration of beta blocker reduced arrhythmias and overall mortality, but was associated with an increased incidence of need for repeat PCI and CABG. (

    What do the rest of you think? should we start giving oral beta blockers to all ACS patients as part of our normal ED management?

  2. I give B-blockers to select patients and have never seen a significant or symptomatic drop in blood pressure. Most studies show benefit, and I think it is reasonable to assume the sooner the better in ACS. We are at the front line and should do everything we can to initiate timely care to improve the outcomes for the patients we treat.

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