Secondary prophylaxis after myocardial infarctionBMJ 1995; 310 doi: http://dx.doi.org/10.1136/bmj.310.6971.61 (Published 07 January 1995) Cite this as: BMJ 1995;310:61
EDITOR,—In writing about secondary prophylaxis after myocardial infarction D L Whitford and A J Southern state that “ß blockers should be given to all patients except those with active reversible airways disease, heart block, or heart failure, and treatment should be continued for at least one year and up to six years in the community.”1 Such dogmatism is not justified, and it would be alarming if such authoritarian statements were used as a criterion on which to evaluate the quality of care given by physicians. The opinions expressed are based on the interpretation of clinical trials. While these trials have clearly shown the prophylactic benefit of this treatment in the subjects recruited, they have included only a minority of the potential patients after infarction. Furthermore, many of those included in the trials had such a good prognosis that one can question the need for ß blockade in similar cases.2 As Chamberlain wrote recently, “In addition to the 30% of patients after infarction who may not tolerate ß blockade, it may be reasonable to define another group of approximately similar size for whom ß blockade is not indicated on grounds of good prognosis.”3
Practice should certainly be based, when possible, on the results of good clinical trials. Interpretations, however, are not straightforward. One should be cautious about elaborating rigid rules on treatment and incorporating them into local protocols. It would be unfortunate if those physicians who believe that one can be selective about the use of ß blockade after infarction were criticised or even penalised for not having achieved a questionable standard.