Case:

58M, anterior STEMI → primary PCI. LVEF 55%. Started on metoprolol in-hospital.
At 8-week follow-up: HR 54, lightheaded, no angina, BP controlled. Continue or taper?

---

Oral beta blocker:

Start early in-hospital: For ACS patients without contraindications, initiate oral β-blocker within 24 hours to reduce reinfarction and ventricular arrhythmias (Class I, Level A).

IV before PPCI:

Routine IV β-blocker is not supported; consider only if symptomatic/another indication, given inconsistent benefit and shock risk.

After discharge, preserved EF:

The optimal duration is unclear; a contemporary randomized trial in revascularized patients with preserved EF did not confirm long-term benefit—ongoing studies noted.

Reduced EF (≤50%)/HF:

Long-term β-blockers remain a cornerstone with established benefit.

Quick ward/clinic algorithm (guideline-consistent)

1. ACS day 0–1: Start low-dose oral β-blocker unless contraindicated; avoid routine IV.
2. Before discharge: Confirm LVEF; if <50% or HF, plan long-term therapy. If ≥50%, document indication (angina, arrhythmia, BP/HR).
3. Follow-up (4–12 weeks):
   • If no clear indication and EF ≥50%, consider gradual taper rather than indefinite continuation (no proven outcome benefit).
   • If indications persist (AF rate control, angina, HTN) or EF <50%, continue and uptitrate as tolerated.

Bottom line: Early use—yes. Automatic, long-term use with preserved EF—no; individualize. That’s exactly what the 2025 ACS guideline says.