Safety of using the intravenous beta-1-adrenoblocker esmolol in patients with ST-segment elevation myocardial infarction before primary percutaneous coronary intervention

Aim. To study the safety of using the intravenous beta-blocker (BB) esmolol in the early stages of ST-segment elevation myocardial infarction (STEMI) before primary percutaneous coronary intervention (PCI) based on an analysis of the incidence and clinical significance of adverse events (acute heart failure, hypotension, bradycardia, disorders of atrioventricular conduction (AV conduction), etc.) compared with the control group.

Material and methods. The presented study is part of the randomized controlled trial ESMO-VASCMI (ClinicalTrials.gov NCT number 06376630) on the study of the cardioprotective effect of IV BB esmolol in the early stages of STEMI. The study included 121 patients (n=60 in the control group and n=61 in the esmolol group) with STEMI in the first 48 hours after the onset of symptoms contraindications to BB, who were not prescribed metoprolol before PCI due to safety concerns. The administration of esmolol began with a loading dose of 500 mcg/kg for 1 minute, followed by an infusion for 6 hours. With the development of adverse events, esmolol therapy was discontinued prematurely or temporarily suspended.

Results. No statistically significant difference was observed in the frequency of adverse events potentially provoked by β1‑blocker administration between the study groups. In the esmolol group, there was a trend toward a higher incidence of bradycardia during PCI (18.03% vs 6.63%, p=0.058); hypotension (down to 70/40 mm Hg) was observed in 2 patients (3.3%), and AHF manifestations in 2 (3.3%). In 4 patients (7%), the infusion was prematurely discontinued, and in 8 (13%) it was temporarily suspended and resumed after hemodynamic stabilization. No cases of bronchospasm were detected. All cases of bradycardia and hypotension were clinically insignificant. Bradycardia developed during reperfusion with PCI, atropine was administered to 2 patients, and esmolol infusion was subsequently resumed. In the esmolol group, there was no development of stable ventricular rhythm disturbances (ventricular fibrillation (VF) or ventricular tachycardia (VT)) on the first day of the disease, in contrast to the control group (n=4; 6.67%). The differences were significant (p=0.04). The incidence of hospital deaths was low (n=1 in the control group), with no significant difference between the study and control groups (0% vs 1.7%).

Conclusion. The study results confirm the favorable safety profile of esmolol. Intravenous esmolol administration reduced the incidence of life-threatening arrhythmias without increasing the frequency of conduction disturbances, bradycardia, or AHF. In most cases, discontinuation of the infusion was sufficient to manage bradycardia in the esmolol group.

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