Beta-Blocker Therapy in CAD: Insights from India's Largest ROBUST Clinician Survey

The study used a 26-item structured survey to evaluate the practice patterns and clinical reasoning on the role of beta-blockers across the cardiovascular continuum, including hypertension, heart failure, post-MI care, CCS, and AF. It was authored by Dr. JS Hiremath, Dr. Arup Dasbiswas, Dr. JPS Sawhney, Dr. Subhash Chandra, Dr. PP Mohanan, Dr. Swati Srivastava, and Ms Baishali Nath.

Some of the key findings in the CAD care continuum include:

Application of Beta Blockers Post-MI at Discharge

● In post-MI management, 39.4% of HCPs reported utilizing β-blockers to >75% of patients at discharge, while an additional 23.2% of HCPs prescribed them to 50–75% of patients. Only 12.4% HCPs reported limiting use to ≤25% of patients.

● Metoprolol was the preferred β-blocker by 78.1% of HCPs for post-MI cases, followed by bisoprolol (17.5%).

● The principal reasons cited for not considering β-blockers post-MI were low heart rate (61.4% of HCPs) and low blood pressure (31.9% of HCPs), indicating that non-use was primarily due to hemodynamic concerns in this patient population.

● Additionally, in the cardiologist subset analysis, more than 95% of HCPs reported clinical application of β-blockers in post-MI care, suggesting near-universal adoption in specialist practice.

Clinical Approach to β-Blocker Therapy in Post-MI and CCS

Speaking to Medical Dialogues, Dr Subhash Chandra, Chairman – Interventional Cardiology & Structural Heart Program BLK-MAX Heart & Vascular Institute, BLK-MAX Super Speciality Hospital, Pusa Road, New Delhi, and a member of the review panel, said- "β-blockers remain a cornerstone of post-MI therapy and should be initiated as soon as the patient is haemodynamically stable. The focus should not be on whether to prescribe β-blockers, but on optimizing their use, particularly in patients with lower heart rates or borderline blood pressure. In such cases, therapy should be individualized by starting with a low, appropriate dose and gradually uptitrating based on tolerance. The survey identified bradycardia and hypotension as the leading reasons for withholding β-blocker therapy, underscoring the importance of carefully balancing efficacy with safety. The significant preference for metoprolol reflects its well-established role and consistent clinical utility across the post-MI continuum. In patients with chronic coronary sydrome (CCS), β-blockers continue to play an important role in both secondary prevention and long-term symptom control. Treatment decisions should be guided by the patient's overall clinical profile, including symptom burden, heart rate, associated cardiovascular comorbidities, and therapeutic goals. Beyond patients with prior MI or reduced ejection fraction, β-blockers also benefit those with persistent angina or a need for heart rate control."

Considering Beta Blockers in Chronic Coronary Syndrome (CCS)

● In CCS, 36.1% of HCPs utilized β-blockers to 25–50% of their patients, while 30.2% of HCPs, reported prescribing them to more than 75% of their CCS patients. A smaller proportion, 12.4% of HCPs, limited use to ≤25% of their CCS patients

● Metoprolol again emerged as the most preferred agent, selected by 82.7% of respondents for CCS management, with bisoprolol chosen by 12.7%. The consistency of agent preference across post-MI and CCS reflects a unified approach to β-blocker selection in stable and post-acute CAD contexts.

● Cardiologists reported even higher use in CCS, with >95% indicating β-blocker prescription in this setting, indicating strong adherence to guideline-aligned antianginal and secondary preventive strategies in tertiary care.

Overall, the study reinforces that β-blockers-particularly metoprolol, remain central to CAD management in India, with prescribing decisions primarily guided by clinical needs and individualized patient profiles.