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Beta-blocker efficacy across different cardiovascular indications: an umbrella review and meta-analytic assessment
Oliver J Ziff1,2, Monica Samra2, James P Howard3
1University of Birmingham Institute of Cardiovascular Sciences, Medical School, Birmingham, B15 2TT, UK.
Insights
Beta-blockers significantly lower mortality in heart failure patients with sinus rhythm. However, for coronary artery disease, surgery, and hypertension, their benefits must be weighed against potential risks.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- Beta-blockers are commonly prescribed for cardiovascular conditions.
- Their effectiveness in current medical practice is not fully established.
Purpose of the Study:
- To evaluate the efficacy of beta-blockers in contemporary cardiovascular disease management.
- To synthesize evidence from meta-analyses of randomized controlled trials.
Main Methods:
- An umbrella review of meta-analyses of randomized controlled trials was conducted.
- Searches included MEDLINE, EMBASE, and Cochrane Library up to December 2018.
- Outcomes assessed included all-cause mortality, myocardial infarction, heart failure, and stroke.
Main Results:
- Beta-blockers showed reduced mortality in coronary artery disease before routine reperfusion but not in contemporary studies.
- In heart failure with reduced ejection fraction and sinus rhythm, beta-blockers decreased mortality and hospitalizations.
- For hypertension, beta-blockers offered no benefit over placebo and were inferior to other agents.
- In non-cardiac surgery, beta-blockers reduced myocardial infarction but increased stroke risk.
Conclusions:
- Beta-blockers are highly effective in reducing mortality for heart failure patients in sinus rhythm.
- For other conditions like coronary artery disease, surgery, and hypertension, the benefits of beta-blockers require careful consideration against potential risks.
Background:
Beta-blockers are widely used for many cardiovascular conditions; however, their efficacy in contemporary clinical practice remains uncertain.
Methods:
We performed a prospectively designed, umbrella review of meta-analyses of randomised controlled trials (RCTs) investigating the evidence of beta-blockers in the contemporary management of coronary artery disease (CAD), heart failure (HF), patients undergoing surgery or hypertension (registration: PROSPERO CRD42016038375). We searched MEDLINE, EMBASE and the Cochrane Library from inception until December 2018. Outcomes were analysed as beta-blockers versus control for all-cause mortality, myocardial infarction (MI), incident HF or stroke. Two independent investigators abstracted the data, assessed the quality of the evidence and rated the certainty of evidence.
Results:
We identified 98 meta-analyses, including 284 unique RCTs and 1,617,523 patient-years of follow-up. In CAD, 12 meta-analyses (93 RCTs, 103,481 patients) showed that beta-blockers reduced mortality in analyses before routine reperfusion, but there was a lack of benefit in contemporary studies where ≥ 50% of patients received thrombolytics or intervention. Beta-blockers reduced incident MI at the expense of increased HF. In HF with reduced ejection fraction, 34 meta-analyses (66 RCTs, 35,383 patients) demonstrated a reduction in mortality and HF hospitalisation with beta-blockers in sinus rhythm, but not in atrial fibrillation. In patients undergoing surgery, 23 meta-analyses (89 RCTs, 19,211 patients) showed no effect of beta-blockers on mortality for cardiac surgery, but increased mortality in non-cardiac surgery. In non-cardiac surgery, beta-blockers reduced MI after surgery but increased the risk of stroke. In hypertension, 27 meta-analyses (36 RCTs, 260,549 patients) identified no benefit versus placebo, but beta-blockers were inferior to other agents for preventing mortality and stroke.
Conclusions:
Beta-blockers substantially reduce mortality in HF patients in sinus rhythm, but for other conditions, clinicians need to weigh up both benefit and potential risk.
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