Ask the Expert - July/August

Joel Schofer, MD
LCDR MC USN, Naval Hospital

“Ask The Expert” is a Common Sense feature where subject matter experts provide answers to questions provided by YPS members. This edition features a leading authority on emergency cardiology, Dr. Amal Mattu.

Question: 

Is it safe to administer beta-blockers to a patient in whom acute myocardial infarction (AMI) versus chronic obstructive pulmonary disease (COPD) exacerbation is undifferentiated? If they are on chronic beta-blocker therapy does this mean that the acute administration will be safe and well tolerated?

Answer:

If the patient has an , beta-blockers are generally recommended even if the patient has a history of COPD (assuming that there is not a concurrent COPD exacerbation). In that scenario, a beta-1 specific blocker such as esmolol would be ideal, because it is titrateable, and it can be turned off if the person develops pulmonary problems. Other beta-1 specific options would be metoprolol or atenolol, though they are not as titrateable.

With that said, however, the recent COMMIT study (the largest modern era study evaluating the use of beta-blockers in acute coronary syndrome (most patients had ST-elevation MI) did not find an overall benefit to early use of beta-blockers. Prior studies demonstrating benefits of beta-blockers were done when aspirin and other antiplatelet agents were not so routinely given. Prior to this study, it was common practice to routinely give beta-blockers to AMI patients very early in the course of treatment. I'd suggest that, based on this study, we shouldn't be in such a rush to throw beta-blockers at the patient until their hemodynamic status is stable or unless they are very tachycardic or perhaps have intractable pain.

If a patient presents with dyspnea and it is uncertain whether the patient has acute coronary syndrome vs. COPD, I'd be hesitant to give any beta-blockers until I'm certain about the diagnosis.

Amal Mattu, MD FAAEM
Program Director, Emergency Medicine Residency
Associate Professor, Department of Emergency Medicine

If you have a question that you would like to have answered by an expert in a future issue of Common Sense, please send it to jschofer@gmail.com.

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government.