Which beta-blockers are recommended for chronic ACS management to reduce cardiovascular mortality when heart rate is stabilized and ejection fraction is reduced?

• A. Metoprolol succinate
• B. Atenolol
• C. Carvedilol
• D. All of the above

Answer: (D)

Starting a beta-blocker after ACS in patients with reduced ejection fraction, once heart rate and hemodynamics are stabilized, lowers long-term cardiovascular mortality by blunting harmful sympathetic activation, reducing arrhythmias, and limiting adverse remodeling of the heart. This survival benefit is seen with multiple agents, not just a single drug. Metoprolol succinate has durable trial data in chronic systolic heart failure (and post-MI with LV dysfunction) showing reduced mortality, making it a common first choice in this setting. Atenolol also has evidence supporting mortality reduction in post-MI and heart failure contexts, providing a viable option when well tolerated. Carvedilol brings benefit through its combined beta and alpha-blockade and is supported by trials in post-MI LV dysfunction as well as heart failure, reinforcing its role in chronic management. Because this is a class effect with proven benefit across these drugs, all of the above are appropriate choices for chronic ACS management when the patient is stabilized and EF is reduced. Start low, titrate gradually, and monitor for bradycardia or hypotension while continuing other guideline-directed therapies.