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Clinical outcomes with β-blockers for myocardial infarction: a meta-analysis of randomized trials
Sripal Bangalore1, Harikrishna Makani2, Martha Radford1
1New York University School of Medicine, New York, NY.
Insights
Beta-blockers (β-blockers) did not reduce mortality in the reperfusion era for myocardial infarction. While they decreased recurrent myocardial infarction and angina short-term, they increased risks of heart failure and cardiogenic shock.
Area of Science:
- Cardiology
- Clinical Trials
- Pharmacology
Background:
- The effectiveness of beta-blockers (β-blockers) in treating myocardial infarction (MI) and their optimal duration of use remain debated in current medical practice.
- Contemporary MI treatment strategies have evolved, necessitating a re-evaluation of established therapies like β-blockers.
Purpose of the Study:
- To evaluate the efficacy of beta-blockers (β-blockers) in reducing mortality and other key outcomes in patients with myocardial infarction (MI).
- To compare the effects of β-blockers in the pre-reperfusion and reperfusion eras of MI treatment.
- To assess the risks and benefits of β-blocker therapy in contemporary MI management.
Main Methods:
- A systematic review and meta-analysis of randomized controlled trials (RCTs) involving β-blockers for MI.
- Trials were identified through comprehensive searches of MEDLINE, EMBASE, and CENTRAL databases.
- Analysis stratified trials into pre-reperfusion and reperfusion eras, with all-cause mortality as the primary outcome.
Main Results:
- Sixty trials with 102,003 patients were included. β-blockers significantly reduced mortality in the pre-reperfusion era but showed no mortality benefit in the reperfusion era.
- In the reperfusion era, β-blockers reduced recurrent MI and angina short-term (30 days) but increased risks of heart failure, cardiogenic shock, and drug discontinuation.
- The number needed to treat to benefit (NNTB) for angina was 26, while the number needed to treat to harm (NNTH) for heart failure was 79.
Conclusions:
- In contemporary myocardial infarction (MI) management, beta-blockers (β-blockers) offer no mortality benefit.
- β-blockers provide short-term benefits for recurrent MI and angina but are associated with increased risks of heart failure, cardiogenic shock, and discontinuation.
- Current guidelines should reassess the strength of recommendations for β-blocker use post-MI.
Background:
Debate exists about the efficacy of β-blockers in myocardial infarction and their required duration of usage in contemporary practice.
Methods:
We conducted a MEDLINE/EMBASE/CENTRAL search for randomized trials evaluating β-blockers in myocardial infarction enrolling at least 100 patients. The primary outcome was all-cause mortality. Analysis was performed stratifying trials into reperfusion-era (> 50% undergoing reperfusion or receiving aspirin/statin) or pre-reperfusion-era trials.
Results:
Sixty trials with 102,003 patients satisfied the inclusion criteria. In the acute myocardial infarction trials, a significant interaction (Pinteraction = .02) was noted such that β-blockers reduced mortality in the pre-reperfusion (incident rate ratio [IRR] 0.86; 95% confidence interval [CI], 0.79-0.94) but not in the reperfusion era (IRR 0.98; 95% CI, 0.92-1.05). In the pre-reperfusion era, β-blockers reduced cardiovascular mortality (IRR 0.87; 95% CI, 0.78-0.98), myocardial infarction (IRR 0.78; 95% CI, 0.62-0.97), and angina (IRR 0.88; 95% CI, 0.82-0.95), with no difference for other outcomes. In the reperfusion era, β-blockers reduced myocardial infarction (IRR 0.72; 95% CI, 0.62-0.83) (number needed to treat to benefit [NNTB] = 209) and angina (IRR 0.80; 95% CI, 0.65-0.98) (NNTB = 26) at the expense of increase in heart failure (IRR 1.10; 95% CI, 1.05-1.16) (number needed to treat to harm [NNTH] = 79), cardiogenic shock (IRR 1.29; 95% CI, 1.18-1.41) (NNTH = 90), and drug discontinuation (IRR 1.64; 95% CI, 1.55-1.73), with no benefit for other outcomes. Benefits for recurrent myocardial infarction and angina in the reperfusion era appeared to be short term (30 days).
Conclusions:
In contemporary practice of treatment of myocardial infarction, β-blockers have no mortality benefit but reduce recurrent myocardial infarction and angina (short-term) at the expense of increase in heart failure, cardiogenic shock, and drug discontinuation. The guideline authors should reconsider the strength of recommendations for β-blockers post myocardial infarction.
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