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Beta-Blocker Therapy After Myocardial Infarction: A Systematic Review and Meta-Analysis of Contemporary Randomized
Stefania Angela Di Fusco1, Andrea Matteucci1, Alessandro Alonzo1
1Clinical and Rehabilitation Cardiology Unit, San Filippo Neri Hospital, ASL Roma 1, 00135 Rome, Italy.
Insights
Beta-blocker therapy after myocardial infarction (MI) shows no clear overall benefit for patients with preserved ejection fraction. Subgroup analyses suggest potential benefits in specific patient groups, warranting further investigation.
Area of Science:
- Cardiology
- Clinical Trials
- Evidence-Based Medicine
Background:
- The established benefits of beta-blockers post-myocardial infarction (MI) primarily apply to patients with reduced left ventricular ejection fraction (LVEF).
- Clinical guidance for beta-blocker use in patients with preserved LVEF after MI remains uncertain.
- Contemporary MI management may influence the efficacy of beta-blocker therapy.
Purpose of the Study:
- To assess the impact of beta-blocker treatment on prognosis after MI.
- To investigate this impact based on MI type (STEMI vs. NSTEMI), LVEF, and patient sex.
- To synthesize evidence from recent randomized clinical trials.
Main Methods:
- Systematic literature search of PubMed and Cochrane Library for randomized clinical trials over the past decade.
- Meta-analysis of trials including patients with LVEF > 40%.
- Subgroup analyses stratified by MI type, LVEF categories, and sex.
Main Results:
- Overall meta-analysis showed no statistically significant association between beta-blocker non-use and adverse composite endpoints.
- Subgroup analyses suggested a potential increased risk with beta-blocker non-use in NSTEMI and mildly reduced LVEF patients, though random-effects estimates were inconsistent.
- No clear associations were found for STEMI, preserved LVEF, or by sex. Sensitivity analyses excluding a specific trial did not alter overall non-significance.
Conclusions:
- Long-term beta-blocker therapy after MI does not demonstrate clear overall benefit or harm in contemporary randomized trials for patients with preserved LVEF.
- Potential benefits in specific subgroups (NSTEMI, mildly reduced LVEF) require confirmation through adequately powered studies.
- Further research with standardized endpoints is needed to clarify beta-blocker efficacy in selected post-MI populations.
Abstract:
The clinical benefit of beta-blocker treatment in patients with a previous myocardial infarction (MI) and without a reduced left ventricular ejection fraction (LVEF) is not established. This study aims at assessing the impact of beta-blocker treatment after an MI based on the type of MI at presentation, the LVEF, and the patient's sex in the setting of contemporary management of MI. We searched the PubMed and Cochrane Library databases for randomized clinical trials published over last ten years that reported beta-blockers' impact on prognosis in patients with LVEF > 40%. A meta-analysis was performed to assess the association between the beta-blocker treatment and outcomes in different patient subgroups based on the type at presentation (with ST segment elevation, STEMI, or without ST segment elevation, NSTEMI), LVEF, and sex. In the overall analysis, the association between beta-blocker non-use and the composite endpoint was not statistically significant under the random-effects model. In subgroup analyses, a higher risk with beta-blocker non-use was suggested in NSTEMI and in patients with mildly reduced LVEF in common-effect estimates (NSTEMI: RR 1.13, 95% CI 1.02-1.25; I2 18%; mildly reduced LVEF: RR 1.24, 95% CI 1.03-1.49; I2 0%), whereas corresponding random-effects estimates were not consistently significant. No clear association was observed in STEMI, preserved LVEF, or by sex. In sensitivity analyses excluding the ABYSS withdrawal trial, the overall association was attenuated and remained non-significant (random-effects RR 1.06, 95% CI 0.84-1.33; I2 35%). Long-term beta-blocker therapy after myocardial infarction showed no clear overall benefit or harm across contemporary randomized trials. Possible signals of benefit in selected subgroups warrant confirmation in adequately powered studies with standardized endpoints.
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