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.”  (

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