Metoprolol/Lopressor

[MasterIntubator]

I have heard some rantings of some ED docs not liking Lopressor to be given in the setting of a hemodynamically stable STEMI in the field. Anyone encounter this? Anyone have Lopressor in thier protocols/or not in thier protocols/or taken out?

I am kinda wondering why we would not give it based on the AHA findings, as I am not finding any new supporting info yet. ( all the printed contraindications and side effects are assumed we already know ).

I have read the COMMIT studies, and other than all the numbers showing that its not that far from placeebo at times.... just looking for some insight across the state lines.

 

[Ridryder911]

Lopressor is a great medication and if you read most of the true cardiac (post AMI) those that were given Lopressor and ACE inhibitors have better long term outcome. One does have to be careful though to be sure that the patient can maintain being hemodynamically stable, as the s/e are bradycardia/hypotension.

R/r 911

 

[Juxel]

Our protocols for it state pt must have HR > 60, SBP > 100, then you can do 5mg IV over 2 minutes followed by 5mg IV every 5 minutes to a max dose of 15mg. If HR drops below 60 or SBP below 100 you stop administration.

 

[fma08]

I don't remember it being in the protocols for an AMI, just for uncontrolled A-Fib w/ RVR and for SVT after the 6,12,12 of adenosine. But that was a while ago, so check with Tydek to be sure.

 

[FL_Medic]

I don't believe AHA supports the administration of Lopressor for STEMI anymore. It was removed from our units.

 

[MasterIntubator]

Thanks FL,

Thats what I was looking for, now to find out why.

 

[RotorFib]

I JUST read this somewhere and now I can't remember what I read it in..EMS or JEMS or some other medical publication.

It was saying that although the short term effects were good, the long term survival rates with admin were worse...something to that effect anyways.

I would appreciate more info as well, we carry this where I work and now I am reluctant to consider it.

 

[DV_EMT]

its on our hospital's formulary and we stock it in their crash carts. Mush be alright down here!

 

[boingo]

Thanks FL,

Thats what I was looking for, now to find out why.

Google COMMIT study, I'm guessing that is why.

 

[MasterIntubator]

..........
I have read the COMMIT studies, and other than all the numbers showing that its not that far from placeebo at times.... just looking for some insight across the state lines.

So I talked to a few docs today... 1 out of 6 knew the answer, which will be in the new AHA changes and guidelines coming out soon. Turns out that Lopressor does not have that great of a success rate if the pt is hemodynamically compromised ( like goes into cardiogenic shock/or the drug causes cardiogenic shock ), and the mortality rate increases rather dramatically then when a beta blocker is on board who's effects last many hours.
They are recommending that once the pt is stabilized within 24 hours, then the cardiologist will entertain the idea of the betas.

 

[emtjack02]

2007: MITRA PLUS a study w/ more then 17,000 pt. It did not look at long term mortality. It strongly recommends the use of acute beta blockers especially in high risk groups.
Miller et. Al, 2007. American Journal of Medicine.
Acute beta-blocker use was associated with lower in-hospital mortality (unadjusted 3.9% vs 6.9%,P _.001, adjusted odds ratio 0.66, 95% confidence interval 0.60-0.72), lower adjusted mortality among most of 6 subgroups determined by propensity to receive acute beta-blockers, and lower adjusted mortality in patients with and without signs of heart failure and in those _80 years and those _80 years old.

Diercks, D, Kontos, M., Weber, J., & Amseterdam, E. Management of STEMI in ED. American Journal of Emergency Medicine (2008).
There was a significant decrease in the secondary end point of rate of reinfarction (2.0% vs 2.5%; P = .001) and ventricular arrhythmias, which was counterbalanced
by an increased risk of cardiogenic shock (5.0% vs 3.9%; P b .001). Patients who had a heart rate of more than 110 beats per minute, a systolic blood pressure of less than 120 mm Hg, and Killip class III, had worse outcomes. On the basis of these results, the investigators advised caution regarding the use of intravenous β-blockers with STEMI in the setting of heart failure and hypotension.

2008 ACC/AHA STEMI and Unstable Angina Guidelines.
Balancing the evidence from COMMIT and the earlierstudies, the ACC/AHA STEMI and UA/NSTEMI guidelinescurrently give Class I (Level of Evidence: B) recommendation for early oral beta-blockers, a Class IIa recommendation for early intravenous beta-blockers in hypertensive patients without specific contraindications (including signs of heartfailure, evidence of a low output state, increased risk for cardiogenic shock [defined as age more than 70 years, systolic blood pressure less than 120 mm Hg, heart rate of 110 bpm or higher, and increased time since onset of symptoms]), and Class III (Level of Evidence: A) (do not recommendation) for intravenous beta-blockers in patients with specific contraindications to early beta-blocker therapy.

Looking at the data I didn’t find anything that said that BB should be not be given, however, several places recommended taking several things into consideration like the ACC/AHA guidelines. The posted above is a quick search and probably is not a large majority of the works out there.
To the last poster..sorry Iam in the reply screen can't see your s/n...thanks that makes alot of sense!
Hope this helps.