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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The guidelines for treatment after myocardial infarction &#40;MI&#41; with or without ST-segment elevation &#40;STEMI or NSTEMI&#41;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1&#8211;3</span></a> recommend the use of beta-blockers for all patients without contraindication because&#44; based on large observational studies and randomized clinical trials&#44; they increase survival rates&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">These guidelines recommend high doses of beta-blockers&#44; but this recommendation is not followed in clinical practice&#44; in which about 25&#37; of the recommended dose is prescribed&#46; Although widely used&#44; these lower doses have not been tested in controlled and randomized trials&#46; The question thus arises as to whether smaller doses of beta-blockers achieve the same benefit in reducing mortality&#44; since the increases in survival in the trials were proportional to the decreases in heart rate obtained with incremental doses&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Studies designed to answer the question of the correct beta-blocker dose have provided important information for the follow-up of MI&#46; The Outcomes of Beta-Blocker Therapy After Myocardial Infarction &#40;OBTAIN&#41; registry&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> of 6682 patients in centers in the USA and Canada from 2007 to 2009 with a mean follow-up of 2&#46;1 years&#44; used multivariate and propensity score analysis to assess the results&#46; No improvement was observed in the survival of patients treated with the higher doses of multiple beta-blockers proposed in the randomized trials&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Similarly&#44; a recently published multicenter registry<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> with 5287 patients discharged on beta-blockers after an acute coronary syndrome &#40;ACS&#41; between 1994 and 2013 showed no difference between the two doses analyzed&#44; &#8804;25&#37; or &#8805;50&#37; of an equivalent daily dose of 200 mg of metoprolol&#46; The authors analyzed the rates of major adverse cardiac events &#40;MACE&#41;&#44; all-cause death&#44; MI&#44; and stroke or equivalent at six months and 24 months of follow-up using multivariate and propensity score analysis&#46; They observed that patients on lower doses had higher rates of myocardial revascularization&#44; an effect that was also seen in the OBTAIN subgroup analysis&#46; The authors further divided the population into two periods&#44; 1993-2003 and 2004-2013&#44; but there was no statistical difference between them&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; Raposeiras-Roubin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> revisit this question&#44; retrospectively analyzing 2092 ACS patients discharged from a single center&#44; the &#193;lvaro Cunqueiro University Hospital of Vigo&#44; between June 2013 and January 2016&#44; and followed for a mean of 18&#46;6&#177;9&#46;7 months&#46; The patients were prescribed various beta-blockers with a predominance of bisoprolol&#46; No prognostic benefit was noted in terms of mortality for high-dose vs&#46; low-dose beta-blockers&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">A meta-analysis published in 2014<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> encompassing sixty clinical trials with 102<span class="elsevierStyleHsp" style=""></span>003 patients compared the effect of beta-blockers at target doses on mortality after MI in the pre- vs&#46; post-reperfusion era&#44; and showed no benefit due to beta-blockers in the post-reperfusion era&#46; Nevertheless&#44; beta-blockers showed benefits for recurrent MI and angina in the reperfusion era&#44; at the expense of increases in heart failure&#44; cardiogenic shock&#44; and drug discontinuation&#44; but appeared to be short term &#40;30 days after discharge&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In the above registries&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">4&#8211;6</span></a> which reflect the translation of guidelines into clinical practice&#44; lower doses of beta-blockers were more frequent and equally useful in reducing cardiac mortality and MACE&#46; These doses were probably selected for a variety of reasons&#44; some objective &#40;hemodynamic limitations and associated respiratory conditions such as reactive airways disease&#41;&#44; and some subjective&#44; such as fatigue&#44; depression and sexual dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">These retrospective registries used robust methods for statistical data analysis&#44; including propensity score analysis and classical regression&#44; to minimize confounding factors such as hypertension&#44; prior STEMI and multivessel coronary artery disease&#44; which are better controlled for in clinical trials&#46; However&#44; they do not provide information on the control of anginal symptoms&#44; blood pressure&#44; heart rate or arrhythmic events&#44; or confirm the extent of patients&#8217; adherence to medication&#46; The mean follow-up of 24 months may not have been sufficient to show significant differences&#44; such as seen in clinical trials&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">It is possible that advanced reperfusion therapies&#44; potent antithrombotics&#44; statins&#44; angiotensin-converting enzyme inhibitors&#44; angiotensin receptor blockers&#44; cardiac rehabilitation&#44; and lifestyle and dietary modifications were responsible for the results observed in the registries&#44; although Allen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> did not observe differences between two periods in the last twenty years&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Several factors are taken into account when considering the optimal dose of beta-blocker therapy&#58; severity and extent of coronary artery disease&#44; presentation &#40;NSTEMI or STEMI&#41; and size of MI&#44; the reperfusion method used &#40;thrombolysis or percutaneous coronary intervention&#41;&#44; presence of residual ischemia&#44; additional non-culprit lesions&#44; revascularization procedures needed in the follow-up period&#44; and assessment of cardiac function&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">On the other hand&#44; beta-adrenergic receptor polymorphisms have been discovered that may be responsible for differences in dose-dependent response and beta-blocker metabolism&#44; with hemodynamic effects such as changes in blood pressure and heart rate&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Recently&#44; a new guideline for the management of acute MI in patients presenting with ST-segment elevation has been published that recommends the use of a beta-blocker&#44; started within 24 hours of hospitalization&#44; in patients without contraindication that should be continued after discharge&#44; with class IIa recommendation and level of evidence B&#46; The contraindications are acute heart failure&#44; hemodynamic instability and higher degree AV block&#44; with the recommendation that doses of proven efficacy should be administered&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Further research should be carried out to compare the effects of different doses of beta-blockers and the factors used to select them in order to improve survival and MACE after MI&#46; Until the results of these studies are available&#44; the best strategy is probably to offer patients the maximum dose tolerated&#44; but lower than the target doses used in the randomized trials&#46; Registries such as that of Raposeiras-Roubin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> support this therapeutic decision while we await publication of new evidence that may change the use of beta-blockers in the follow-up of patients with MI&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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