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Influence of left ventricular systolic function on the long-term benefit of beta-blockers after ST-segment elevation
Jesús Velásquez-Rodríguez1, Vanesa Bruña1, Lourdes Vicent1
1Department of Cardiology. Hospital General Universitario Gregorio Marañón, CIBERCV, Madrid, Spain.
Insights
Beta-blockers after ST-elevation myocardial infarction (STEMI) show reduced mortality in patients with reduced ejection fraction. Their benefit in patients with preserved ejection fraction remains uncertain, necessitating further clinical trials.
Area of Science:
- Cardiology
- Clinical Research
- Pharmacology
Background:
- Beta-blockers are standard post-ST-elevation myocardial infarction (STEMI) treatment.
- Their efficacy in patients with preserved left ventricular ejection fraction (LVEF) is not well-established.
Purpose of the Study:
- To evaluate the association of beta-blocker use at discharge with mortality after STEMI.
- To investigate this association specifically in patients with preserved LVEF (LVEF >40%).
Main Methods:
- Retrospective analysis of 972 patients discharged in sinus rhythm after STEMI.
- Follow-up until December 2017 to assess mortality.
- Subgroup analysis based on LVEF (≤40% vs. >40%).
Main Results:
- Beta-blocker use at discharge was associated with lower mortality (HR 0.61, p=0.03).
- This benefit was significant in patients with LVEF ≤40% (HR 0.57, p=0.04).
- No significant association was found in patients with LVEF >40% (HR 0.67, p=0.42).
Conclusions:
- The systematic use of beta-blockers in STEMI patients with preserved LVEF warrants further investigation.
- Large randomized clinical trials are needed to clarify the benefit of beta-blockers in this specific patient group.
Introduction:
Beta-blockers are recommended after ST-elevation myocardial infarction (STEMI), but their benefit in patients with preserved left ventricular ejection fraction (LVEF) is unclear.
Methods:
Consecutive patients discharged in sinus rhythm after STEMI between January 2010 and April 2015 were followed until December 2017. Percutaneous coronary intervention (PCI) was performed in 969 (99.7%, including 112 with rescue PCI) and three (0.3%) received only thrombolytic therapy without rescue PCI.
Results:
Of these 972 patients, mean age 62.6±13.5 years, 212 (21.8%) were women and 835 (85.9%) were prescribed beta-blockers at discharge. Patients who did not receive beta-blockers had more comorbidities than those who did, including chronic obstructive pulmonary disease (14.6% vs. 4.2%), anemia (8.0% vs. 3.7%), and cancer (7.3% vs. 2.8%), and more frequently had inferior STEMI (75.9% vs. 56.0%) and high-grade atrioventricular block (13.1% vs. 5.3%) (all p<0.01). After a mean follow-up of 49.6±24.9 months, beta-blocker treatment at discharge was independently associated with lower mortality (HR 0.61, 95% confidence interval [CI] 0.38-0.96, p=0.03). This effect was present in 192 patients with LVEF ≤40% (HR 0.57, 95% 95% CI 0.34-0.97, p=0.04) but was not clear in 643 patients with LVEF >40% (HR 0.67, 95% 95% CI 0.25-1.76, p=0.42).
Conclusion:
In the LVEF >40% group, the results raise reasonable doubts about the real benefit of systematic use of beta-blockers as treatment for these patients. These findings reinforce the need for large randomized clinical trials within this group of patients.
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