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Metoprolol IV for Heart Attack

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The METOCARD-CNIC Trial in Spain recently showed that giving the low cost medication Metoprolol in the field for patients experiencing a heart attack may prove to be beneficial. How many of you carry & administer IV Metoprolol to patients experiencing heart attacks in the field?

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I am not sure this study alone is enough to compel a paradigm shift in clinical practice. Many people will likely point to the COMMIT trial where larger numbers of patients in IV Beta blocker groups developed cardiogenic shock. Of course, the COMMIT trial was published back when primary PCI was less prevalent. In addition, the primary end-point of infarct size used in the METOCARD-CNIC trial is nice, but what about compelling clinical outcomes? This is certainly an interesting development and may open the floodgates for additional Beta blocker trials in contemporary times where PCI plays such an important role.

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I didn't see that they were doing it pre-hospitally. IV metoprolol may have some benefit over PO but definitely something should be given within the first 24 hours provided there are no contraindications. The COMMIT trial used some pretty hefty doses of beta blockers so the results weren't all that surprising.

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Medscape did a decent summary write up a few weeks back.

I'm surprised it took this long after the COMMIT study for someone to take another look at this and realize that it was justified to continue to do what many doctors (ER and cardiology) were doing; ie give metoprolol to STEMI patient's that actually needed it, and withhold it from the ones that didn't need it.

What the COMMIT study showed was that if you indiscrimenently give a beta-blocker to all patient's having a MI many will end up in cardiogenic shock; it did not show that metoprolol is detrimental for all MI patient's, but that was the conclusion that the authors came to, and many readers accepted.

This will at least give people justification for treating the hypertensive, tachycardic STEMI's with no contraindications a beta-blocker.

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I'm not so bold as to definitively state it's bad; however, the evidence (yet) is not compelling me to champion for sweeping changes of guidelines. We will see what the next couple of years bring as the 2015 guideline recommendations are right around the corner. Of course, that's not to say they always get it right.

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Well, beta-blockers have always remained in AHA's guidelines for the intial treatement of STEMI's for certain subsets of patients as a class 2a recommendation; I don't know that this one study is enough to up the recommendation nor do I think that 1 relatively small study should be enough.

What this hopefully will do is get people to take a second look at the COMMIT results and realize that the general conclusion reached there makes little sense, get people to start treating patient's on a more individual basis instead of as a group (not every STEMI needs, or should get beta-blockers), and provide further justification for using beta-blockers for some, not all, STEMI's.

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I seem to remember reading somewhere, that there was a study done that took into account pre-hospital Metoprolol and the outcomes showed no positive effects if given pre-hospitally, provided it was given within the first 24 hours. We had it previously and had it removed from our protocols.

BAYAMedic

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I was researching REMSA in Reno, NV because I wanted to do my paramedic internship there. I know that paramedics can administer 5 mg Metoprolol IV x1 in STEMI if SBP > 140 and HR > 100. Critical Care Paramedics and Registered Nurses may administer Metoprolol x3 in STEMI if SBP >90 and HR > 60, may be given with nitroglycerin infusion.

http://www.remsa-cf.com/remsa-protocols-aug-2012.pdf

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If you look at the study, you can clearly see that there was some benefit to giving Metoprolol. Does that mean we should give Metoprolol to everyone, probably not, but I think the point that the authors were trying to make is that if we can reduce the size of an AMI and decrease heart muscle damage then we can reduce the associated problems that follow like CHF which can not only be costly but very debilitating.

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