Metoprolol in Coronary Artery Disease: Top 5 Evidence Insights

Coronary Artery Disease-A Concerning Epidemiology in India:

India has the highest burden of acute coronary syndrome and ST-elevation myocardial infarction (STEMI). The prevalence of CAD in Indians living in India is 21.4% for diabetics and 11% for non-diabetics. The burden of CAD in rural parts of the country is nearly half compared to that in the urban population. Indians are liable to get hospitalized 2–4 times more frequently for complications of CAD, and admission rates are 5–10 times higher for populations younger than 40 years. (1)

Management of Coronary Artery Disease (CAD): Overview

The hallmark of the pathophysiology of CAD is atherosclerotic plaque formation. Treatment options for CAD range from lifestyle changes and medications to more complex invasive procedures. Medications like statins, anti-platelet agents, and beta-blockers aim to manage outcomes and remain the main-stay pharmacotherapy in CAD management. In severe cases, interventions such as percutaneous coronary intervention (PCI) and the more invasive coronary artery bypass grafting (CABG) may be necessary. (2)

Guidelines on Management of Coronary Artery Disease:

ESC Guidelines for the management of Acute Coronary Syndrome(ACS): Beta-blockers should be considered at the time of presentation in patients with a working diagnosis of STEMI undergoing PPCI with no signs of acute HF, a systolic blood pressure (SBP) >120 mmHg, and without other contraindications. (3)

AHA/ACC Multisociety Chronic Coronary Disease (CCD) Guidelines: In patients with CCD and LVEF < 40% with or without previous MI, the use of beta-blocker therapy is recommended to reduce the risk of future Major Adverse CardioVascular Events (MACE), including cardiovascular death. In patients with CCD and LVEF <50%, the use of sustained-release metoprolol succinate, carvedilol, or bisoprolol with titration to target doses is recommended in preference to other beta-blockers. (4)

ESC guidelines for the management of chronic coronary syndromes (CCS): Initial treatment with beta-blockers and/or CCBs to control heart rate and symptoms is recommended for most patients with chronic coronary syndrome. (5)

Role of Metoprolol in Coronary Artery Disease:

Metoprolol is a cardio-selective beta blocker, due to which beta 1 receptors in the heart are blocked, which in turn decreases heart rate and contractility, thus decreasing cardiac output. Hence, there is an increase in diastolic filling time, a reduction in myocardial oxygen demand, and an increase in coronary perfusion that results in anti-ischemic effects. (6)

Metoprolol in CAD: Revisiting the Clinical Evidence:

1. Metoprolol reduces the risk of MACE and recurrent MI: 860 individuals were enrolled who suffered PMI following percutaneous coronary intervention procedure. Out of 860, 456 patients received metoprolol treatment. Metoprolol treatment following Percutaneous Coronary Intervention-related Periprocedural Myocardial Infarction has decreased the subsequent risk of MACEs, particularly the risk of recurrent MI and revascularization. (7)

2. Metoprolol is preferred post-PCI by Indian Cardiologists: A survey and virtual meetings with Indian cardiologists (interventional: n = 256; non-interventional: n = 336) treating hypertensive patients post-PCI captured their management practices and BP control strategies. The findings revealed that metoprolol is the preferred beta-blocker for post-PCI management and heart failure. Additionally, the survey reported that 77% of Indian cardiologists consider metoprolol the drug of choice for post-PCI management. (8)

3. Long-term benefit of beta blockers following MI: A review article by Joseph, Philip et al. examines the current evidence for beta-blockers in heart failure and coronary artery disease. Over the long term (i.e., several months up to 3 years), benefits of β-blockers following MI were also conducted prior to the reperfusion area and demonstrated that β-blockers reduce mortality by approximately 20% and recurrent MI by 23%. (9)

4. Metoprolol is safer in asthma patients with CVD: In a recently published Food and Drug Administration’s Adverse Event Reporting System (FAERS) safety database of beta blockers and asthma, it is suggested that in patients with asthma or at risk of asthma, esmolol, metoprolol, nebivolol, and nadolol should be preferred because of their lower risk profile, whereas betaxolol, bisoprolol, acebutolol, propranolol, and timolol should be avoided because of their higher risk of inducing asthma-related events. (10)

5. Metoprolol is preferred to target heart rate in heart failure: A national consensus meeting in India with 49 specialists (cardiologists, nephrologists, and endocrinologists assessed the role of beta-blockers in heart failure management. The findings highlight the use of beta-blockers in heart failure. Sympathetic overdrive is a common feature associated with heart failure, and achieving a target heart rate with metoprolol may maximize survival benefits over other beta-blockers. (11)

Take Home Message:

• India has the highest burden of acute coronary syndrome (ACS) and ST-elevation myocardial infarction (STEMI), with half of the cases in the urban population and 5–10 times higher for populations younger than 40 years.
• Medications like statins, anti-platelet agents, and beta-blockers aim to improve outcomes and remain the main-stay pharmacotherapy in CAD management.
• Various clinical practice guidelines (CPGs) recommend beta-blockers in patients with Coronary Artery Disease(CAD) when clinically indicated to improve cardiovascular outcomes.
• Metoprolol is a preferred beta-blocker by Indian cardiologists in post-PCI patients. Recently published FAERS safety database has suggested metoprolol among the safer beta-blocker considerations when there is CV indication as compared to bisoprolol.

References

1. A Sreenivas Kumar et al. Cardiovascular disease in India: A 360-degree overview. Med J Armed Forces India 2020; 76(1); PMC6994761.

2. Rai Dilawar Shahjehan et al. Coronary Artery Disease. Treasure island (FL): Statpearls publishing; Jan 2025.

3. Robert A Byrne et al. 2023 ESC Guidelines for the management of acute coronary syndromes: Developed by the task force on the management of acute coronary syndromes of the European Society of Cardiology (ESC). Eur Heart J 2023; 44(38): 3720-3826.

4. David E Winchester. 2023 Chronic Coronary Disease Guideline at a glance. Journal of American College of Cardiology 2023; 82(9).

5. Christian Vrintss et al. 2024 ESC Guidelines for the management of chronic coronary syndromes: Developed by the task force for the management of chronic coronary syndromes of the European Society of Cardiology (ESC) Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS). European Heart Journal 2024; 45,(36); 3415–3537.

6. Omer Khan et al. Beta blockers in the prevention and treatment of Ischemic Heart Disease: Evidence and Clinical Practice. Heart Views 2023; 24(1): 41-9.

7. Duanbin Li et al. Effect of Metoprolol on Periprocedural Myocardial Infarction After Percutaneous Coronary Intervention (Type 4a MI): An Inverse Probability of Treatment Weighting Analysis. Front Cardiovasc Med. 2021; 23;8: 746988.

8. A Sreenivas Kumar et al. Hypertension management in Pre and Post Percutanous Coronary Intervention patients: An Expert opinion of Cardiologists from India. J Pract Cardiovasc sci 2024;10:18-24.

9. Philip Joseph et al. The Evolution of beta blockers in Coronary artery disease and Heart Failure. J of Am Coll of Cardiol 2019; 74(5); 672-82.

10. Mario Cazzola et al. Beta blockers and asthma: surprising findings from the FAERS database. Respiratory medicine 2024; 234; 107849.

11. H K Chopra et al. Sympathetic overdrive and role of beta blockers in various forms of heart failure: A consensus statement from India. J of asso of phy of India 2024; 72(11) e32-39.