Clinical outcomes with β-blockers for myocardial infarction: a meta-analysis of randomized trials

De-escalation of antianginal medications after successful chronic total occlusion percutaneous coronary intervention: Frequency and relationship with health status

BACKGROUND

Successful chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can markedly reduce angina symptom burden, but many patients often remain on multiple antianginal medications (AAMs) after the procedure. It is unclear when, or if, AAMs can be de-escalated to prevent adverse effects or limit polypharmacy. We examined the association of de-escalation of AAMs after CTO PCI with long-term health status.

METHODS

In a 12-center registry of consecutive CTO PCI patients, health status was assessed at 6 months after successful CTO PCI with the Seattle Angina Questionnaire and the Rose Dyspnea Scale. Among patients with technical CTO PCI success, we examined the association of AAM de-escalation with 6-month health status using multivariable models adjusting for revascularization completeness and predicted risk of post-PCI angina (using a validated risk model). We also examined predictors and variability of AAMs de-escalation.

RESULTS

Of 669 patients with technical success of CTO PCI, AAMs were de-escalated in 276 (35.9%) patients at 1 month. Patients with AAM de-escalation reported similar angina and dyspnea rates at 6 months compared with those whose AAMs were reduced (any angina: 22.5% vs 20%, P = .43; any dyspnea: 51.8% vs 50.1%, P = .40). In a multivariable model adjusting for complete revascularization and predicted risk of post-PCI angina, de-escalation of AAMs at 1 month was not associated with an increased risk of angina, dyspnea, or worse health status at 6 months.

CONCLUSIONS

Among patients with successful CTO PCI, de-escalation of AAMs occurred in about one-third of patients at 1 month and was not associated with worse long-term health status.

Misconceptions and Facts About Beta-Blockers

Beta-blockers are commonly used medications, and they have been traditionally considered "cardioprotective." Their clinical use appears to be more widespread than the available evidence base supporting their role in cardioprotection. Beta-blockers counteract neurohumoral activation in heart failure with reduced ejection fraction and offer both symptomatic improvement and reduction in adverse events. On the other hand, the use of beta-blockers in uncomplicated hypertension results in suboptimal outcomes compared to the established first-line antihypertensive agents. Providers at all levels should be familiar with common misconceptions regarding beta-blocker use in routine clinical practice.

Stable Angina Medical Therapy Management Guidelines: A Critical Review of Guidelines from the European Society of Cardiology and National Institute for Health and Care Excellence

Most patients with stable angina can be managed with lifestyle changes, especially smoking cessation and regular exercise, along with taking antianginal drugs. Randomised controlled trials show that antianginal drugs are equally effective and none of them reduced mortality or the risk of MI, yet guidelines prefer the use of beta-blockers and calcium channel blockers as a first-line treatment. The European Society of Cardiology guidelines for the management of stable coronary artery disease provide classes of recommendation with levels of evidence that are well defined. The National Institute for Health and Care Excellence (NICE) guidelines for the management of stable angina provide guidelines based on cost and effectiveness using the terms first-line and second-line therapy. Both guidelines recommend using low-dose aspirin and statins as disease-modifying agents. The aim of this article is to critically appraise the guidelines’ pharmacological recommendations for managing patients with stable angina.

Angina and left ventricular dysfunction: can we 'reduce' it?

Despite the evolution in pharmacology and devices, recurrent and persistent angina still represent a frequent issue in clinical practice. A 69-year-old Caucasian female patient has history of surgical aortic valve replacement with a bioprosthesis for severe aortic stenosis with subsequent transcatheter valve-in-valve implantation for bioprosthesis degeneration and single coronary artery bypass graft with left internal mammary artery on left anterior descending (LAD). After transcatheter aortic valve implantation, she started to complain angina [Canadian Cardiovascular Society (CCS) Class III], effectively treated with bisoprolol uptitration and ivabradine 5 b.i.d. addition. After 6 months, she had a non-ST segment elevated myocardial infarction with evidence of left main occlusion and good functioning aortic bioprosthesis. A retrograde drug-eluting balloon percutaneous coronary intervention (PCI) on LAD (in-stent restenosis) was performed. However, the patient continued to complain angina (CCS Class II-III), even after further ivabradine increase to 7.5 mg b.i.d. After 4 months, the patient underwent Reducer implantation. After 2 months, angina started to improve and the patient is currently angina free. In the last decades, PCI materials and stents greatly improved. Medical therapy (such as β-blockers) has been shown not only to improve symptoms but also to add a prognostic benefit in patients with reduced ejection fraction (EF). Ivabradine showed additional benefits in patients with angina and reduced EF. However, still a relevant portion of patients complain refractory angina. The COSIRA trial showed that a coronary sinus Reducer was associated with greater angina relief than the sham procedure and could be a further step in angina treatment.

Admission Heart Rate Is a Determinant of Effectiveness of Beta-Blockers in Acute Myocardial Infarction Patients

BACKGROUND

Beta-blockers are standard therapy for acute myocardial infarction (AMI). However, despite current advances in the management of AMI, it remains unclear whether all AMI patients benefit from β-blockers. We investigated whether admission heart rate (HR) is a determinant of the effectiveness of β-blockers for AMI patients. Methods and Results: We enrolled 3,283 consecutive AMI patients who were admitted to 28 participating institutions in the Japanese Registry of Acute Myocardial Infarction Diagnosed by Universal Definition (J-MINUET) study. According to admission HR, we divided patients into 3 groups: bradycardia (HR <60 beats/min, n=444), normocardia (HR 60 to ≤100 beats/min, n=2,013), and tachycardia (HR >100 beats/min, n=342). The primary endpoint was major adverse cardiac events (MACE), including all-cause death, non-fatal MI, non-fatal stroke, heart failure (HF), and urgent revascularization for unstable angina, at 3-year follow-up. Beta-blocker at discharge was significantly associated with a lower risk of MACE in the tachycardia group (23.6% vs. 33.0%; P=0.033), but it did not affect rates of MACE in the normocardia group (17.8% vs. 18.4%; P=0.681). In the bradycardia group, β-blocker use at discharge was significantly associated with a higher risk of MACE (21.6% vs. 12.7%; P=0.026). Results were consistent for multivariable regression and stepwise multivariable regression.

CONCLUSIONS

Admission HR might determine the efficacy of β-blockers for current AMI patients.

Effect of oral β-blocker treatment on mortality in contemporary post-myocardial infarction patients: a systematic review and meta-analysis

Aims

Guidelines concerning β-blocker treatment following acute myocardial infarction (AMI) are based on studies undertaken before the implementation of reperfusion and secondary prevention therapies. We aimed to estimate the effect of oral β-blockers on mortality in contemporary post-AMI patients with low prevalence of heart failure and/or reduced left ventricular ejection fraction.

Methods and results

A random effects model was used to synthetize results of 16 observational studies published between 1 January 2000 and 30 October 2017. Publication bias was evaluated, and heterogeneity between studies examined by subgroup and random effects meta-regression analyses considering patient-related and study-level variables. The pooled estimate showed that β-blocker treatment [among 164 408 (86.8%) patients, with median follow-up time of 2.7 years] was associated with a 26% reduction in all-cause mortality [rate ratio (RR) 0.74, 95% confidence interval (CI) 0.64–0.85] with moderate heterogeneity (I² = 67.4%). The patient-level variable mean age of the cohort explained 31.5% of between study heterogeneity. There was presence of publication bias, or small study effect, and when controlling for bias by the trim and fill simulation method, the effect disappeared (adjusted RR 0.90, 95% CI 0.77–1.04). Also, small study effect was demonstrated by a cumulative meta-analysis starting with the largest study showing no effect, with increasing effect as the smaller studies were accumulated.

Conclusion

Evidence from this study suggests that there is no association between β-blockers and all-cause mortality. A possible beneficial effect in AMI survivors needs to be tested by large randomized clinical trials.

Beta-blockers for post-acute coronary syndrome mid-range ejection fraction: a nationwide retrospective study

BACKGROUND

Patients with mid-range ejection fraction (40-49%) are in focus due to the newly defined entity of heart failure with mid-range ejection fraction. Acute coronary syndromes are a major aetiology for heart failure with mid-range ejection fraction. We aim to evaluate which therapeutic decisions are associated with inhospital survival benefit in post-acute coronary syndrome patients categorised according to the ejection fraction.

METHODS AND RESULTS

The authors analysed a cohort of a multicentre national registry enrolling acute coronary syndrome patients between 2010 and 2016, classified according to their ejection fraction before hospital discharge. Patients with previously known heart failure or with no ejection fraction evaluation were excluded. A total of 9429 patients were included and categorised in three groups: (a) ejection fraction of 50% or greater (n=6113, 65%); (b) ejection fraction of 40-49% (n=1926, 20%); and (c) ejection fraction less than 40% (n=1390, 15%). The primary endpoint was inhospital mortality. To eliminate confounding factors, a multivariate logistic regression analysis was conducted, including acute coronary syndrome type, baseline characteristics, pharmacological treatment, clinical data, laboratory data and coronary anatomy when known. The overall inhospital mortality was 2.8% (n=263): 0.9% (n=53) in group 1, 2.4% (n=37) in group 2 and 11.4% (n=159) in group 3. After multivariate analysis, an invasive strategy had a positive impact in all groups, inhospital beta-blocker administration had a positive impact for groups 2 and 3, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and spironolactone had a positive impact on group 3.

CONCLUSION

Post-acute coronary syndrome mid-range ejection fraction patients represent an intermediate risk group in which beta-blocker administration was associated with inhospital survival benefit. An invasive strategy was a survival predictor for all groups, regardless of ejection fraction category.

BEtablocker Treatment After acute Myocardial Infarction in revascularized patients without reduced left ventricular ejection fraction (BETAMI): Rationale and design of a prospective, randomized, open, blinded end point study

BACKGROUND

Current guidelines on the use of β-blockers in post-acute myocardial infarction (MI) patients without reduced left ventricular ejection fraction (LVEF) are based on studies before the implementation of modern reperfusion and secondary prevention therapies. It remains unknown whether β-blockers will reduce mortality and recurrent MI in contemporary revascularized post-MI patients without reduced LVEF.

DESIGN

BETAMI is a prospective, randomized, open, blinded end point multicenter study in 10,000 MI patients designed to test the superiority of oral β-blocker therapy compared to no β-blocker therapy. Patients with LVEF ≥40% following treatment with percutaneous coronary intervention or thrombolysis and/or no clinical signs of heart failure are eligible to participate. The primary end point is a composite of all-cause mortality or recurrent MI obtained from national registries over a mean follow-up period of 3 years. Safety end points include rates of nonfatal MI, all-cause mortality, ventricular arrhythmias, and hospitalizations for heart failure obtained from hospital medical records 30 days after randomization, and from national registries after 6 and 18 months. Key secondary end points include recurrent MI, heart failure, cardiovascular and all-cause mortality, and clinical outcomes linked to β-blocker therapy including drug adherence, adverse effects, cardiovascular risk factors, psychosocial factors, and health economy. Statistical analyses will be conducted according to the intention-to-treat principle. A prespecified per-protocol analysis (patients truly on β-blockers or not) will also be conducted.

CONCLUSIONS

The results from the BETAMI trial may have the potential of changing current clinical practice for treatment with β-blockers following MI in patients without reduced LVEF. EudraCT number 2018-000590-75.

Prognostic Impact of β-Blocker Dose After Acute Myocardial Infarction

BACKGROUND

The differential prognostic impact of β-blocker dose after acute myocardial infarction (AMI) has been under debate. The current study sought to compare clinical outcome after AMI according to β-blocker dose using the Korea Acute Myocardial Infarction Registry-National Institutes of Health (KAMIR-NIH). Methods and Results: Of the total population of 13,104 consecutive AMI patients enrolled in the KAMIR-NIH, the current study analyzed 11,909 patients. These patients were classified into 3 groups (no β-blocker; low-dose [<25% of target dose]; and high-dose [≥25% of target dose]). The primary outcome was cardiac death at 1 year. Compared with the no β-blocker group, both the low-dose and high-dose groups had significantly lower risk of cardiac death (HR, 0.435; 95% CI: 0.363-0.521, P<0.001; HR, 0.519; 95% CI: 0.350-0.772, P=0.001, respectively). The risk of cardiac death, however, was similar between the high- and low-dose groups (HR, 1.194; 95% CI: 0.789-1.808, P=0.402). On multivariable adjustment and inverse probability weighted analysis, the result was the same.

CONCLUSIONS

The use of β-blockers in post-AMI patients had significant survival benefit compared with no use of β-blockers. There was no significant additional benefit of high-dose β-blockers compared with low-dose β-blockers, however, in terms of 1-year risk of cardiac death.

Preoperative Management of Medications

Increasingly complex medication regimens for many comorbidities in patients for planned surgical and procedural interventions necessitate detailed preoperative evaluation of the pharmacologic therapy, including the indications, the specific drugs, and dosing amount and interval. The implications of continuing or withholding these agents in the perioperative period need to be elucidated, as well as the risks of interactions and side effects. A comprehensive plan of the management of the therapeutic agents should be devised during the preoperative visit, with input from all relevant specialists, and clearly communicated to the patients in a format that ensures their comprehension and consistent compliance.

Sympathetic overactivity in dialysis patients-Underappreciated and clinically consequential

Cardiovascular morbidity and mortality remain frustratingly common in dialysis patients. A dearth of established evidence-based treatment calls for alternative therapeutic avenues to be embraced. Sympathetic hyperactivity, predominantly due to afferent nerve signaling from the diseased native kidneys, has been established to be prognostic in the dialysis population for over 15 years. Despite this, tangible therapeutic interventions have, to date, been unsuccessful and the outlook for patients remains poor. This narrative review summarizes established experimental and clinical data, highlighting recent developments, and proposes why interventions to ameliorate sympathetic hyperactivity may well be beneficial for this high-risk population.

Through the Decades: β-Blocker Use and Outcomes in Acute Coronary Syndromes

Beta-adrenergic receptor antagonists, or β-blockers, have been a cornerstone of treatment in patients with acute coronary syndromes (ACS) for more than 4 decades. First studied in the 1960s, β-blockers in ACS have been shown to decrease the risk of death, recurrent ischemic events, and arrhythmias by reducing catecholamine-mediated effects and reducing myocardial oxygen demand. Through the decades, the β-blocker of choice, timing of initiation, duration of therapy, and dosing have evolved considerably. Despite having clear benefits in certain patient populations (eg, patients with systolic dysfunction who are hemodynamically stable), the benefit of β-blockers in other populations (ie, in patients at low risk for complications receiving modern revascularization therapies and optimal medical management) remains unclear. This article provides a review of the landmark clinical trials of β-blockers in ACS and highlights the chronology and evolution of guideline recommendations through the decades.

Rationale for administering beta-blocker therapy to patients undergoing coronary artery bypass surgery: a systematic review

INTRODUCTION

Secondary preventative therapies are essential for patients undergoing coronary artery bypass graft (CABG) surgery to optimize perioperative and long-term outcomes. Beta-blockers are commonly used to treat patients with coronary artery disease and congestive heart failure (CHF), but their role for CABG patients remains unclear. The goal of this systematic review was to evaluate the rationale for administering beta-blockers to the CABG population and to assess their efficacy before and after coronary surgical revascularization.

AREAS COVERED

A systematic literature review was performed to retrieve relevant articles from the PubMed database published between 1985 and 2017.

EXPERT OPINION

Outside of the surgical field, strong evidence supports the use of beta-blockers for patients with a history of previous myocardial infarction (MI) or CHF. For the CABG population, studies have suggested that perioperative beta-blocker therapy is beneficial, with an associated reduction in mortality, particularly among those with a history of previous MI or CHF. Beta-blocker administration has also clearly been shown to lower the rate of new-onset postoperative atrial fibrillation after CABG. Among the different types of beta-blockers, perioperative carvedilol appears to be the most beneficial. In the absence of contraindications, nearly all CABG patients are candidates for perioperative beta-blocker therapy.

Pharmacological heart rate lowering in patients with a preserved ejection fraction-review of a failing concept

Epidemiological studies have demonstrated that high resting heart rates are associated with increased mortality. Clinical studies in patients with heart failure and reduced ejection fraction have shown that heart rate lowering with beta-blockers and ivabradine improves survival. It is therefore often assumed that heart rate lowering is beneficial in other patients as well. Here, we critically appraise the effects of pharmacological heart rate lowering in patients with both normal and reduced ejection fraction with an emphasis on the effects of pharmacological heart rate lowering in hypertension and heart failure. Emerging evidence from recent clinical trials and meta-analyses suggest that pharmacological heart rate lowering is not beneficial in patients with a normal or preserved ejection fraction. This has just begun to be reflected in some but not all guideline recommendations. The detrimental effects of pharmacological heart rate lowering are due to an increase in central blood pressures, higher left ventricular systolic and diastolic pressures, and increased ventricular wall stress. Therefore, we propose that heart rate lowering per se reproduces the hemodynamic effects of diastolic dysfunction and imposes an increased arterial load on the left ventricle, which combine to increase the risk of heart failure and atrial fibrillation. Pharmacologic heart rate lowering is clearly beneficial in patients with a dilated cardiomyopathy but not in patients with normal chamber dimensions and normal systolic function. These conflicting effects can be explained based on a model that considers the hemodynamic and ventricular structural effects of heart rate changes.

Treatment of Angina: Where Are We?

Ischaemic heart disease is a major cause of death and disability worldwide, while angina represents its most common symptom. It is estimated that approximately 9 million patients in the USA suffer from angina and its treatment is challenging, thus the strategy to improve the management of chronic stable angina is a priority. Angina might be the result of different pathologies, ranging from the “classical” obstruction of a large coronary artery to alteration of the microcirculation or coronary artery spasm. Current clinical guidelines recommend antianginal therapy to control symptoms, before considering coronary artery revascularization. In the current guidelines, drugs are classified as being first-choice (beta-blockers, calcium channel blockers, and short-acting nitrates) or second-choice (ivabradine, nicorandil, ranolazine, trimetazidine) treatment, with the recommendation to reserve second-line modifications for patients who have contraindications to first-choice agents, do not tolerate them, or remain symptomatic. However, such a categorical approach is currently questioned. In addition, current guidelines provide few suggestions to guide the choice of drugs more suitable according to the underlying pathology or the patient comorbidities. Several other questions have recently emerged, such as: is there evidence-based data between first- and second-line treatments in terms of prognosis or symptom relief? Actually, it seems that newer antianginal drugs, which are classified as second choice, have more evidence-based clinical data that are more contemporary to support their use than what is available for the first-choice drugs. It follows that actual guidelines are based more on tradition than on evidence and there is a need for new algorithms that are more individualized to patients, their comorbidities, and pathophysiological mechanism of chronic stable angina.

Registry-based randomised clinical trial: efficient evaluation of generic pharmacotherapies in the contemporary era

Randomised clinical trials are the gold standard for testing the effectiveness of clinical interventions. However, increasing complexity and associated costs may limit their application in the investigation of key cardiovascular knowledge gaps such as the re-evaluation of generic pharmacotherapies. The registry-based randomised clinical trial (RRCT) leverages data sampling from nationwide quality registries to facilitate high participant inclusion rates at comparably low costs and, therefore, may offer a mechanism by which such clinical questions may be answered. To date, a number of studies have been conducted using such trial designs, but uncritical use of the RRCT design may lead to erroneous conclusions. The current review provides insights into the strengths and weaknesses of the RRCT, as well as provides an exploratory example of how a trial may be designed to test the long-term effectiveness of beta blockers in patients with myocardial infarction who have preserved left ventricular systolic function.

Risk of All-Cause Mortality in Diabetic Patients Taking β-Blockers

OBJECTIVE

To assess the relationship between use of β-blockers and all-cause mortality in patients with and without diabetes.

PATIENTS AND METHODS

Using data from the US National Health and Nutrition Examination Survey 1999-2010, we conducted a prospective cohort study. The study participants were followed-up from the survey participation date until December 31, 2011. We used a Cox proportional hazards model for all-cause mortality analysis. The multivariate-adjusted hazard ratios (HRs) of the participants taking β-blockers were compared with those of the participants not taking β-blockers.

RESULTS

This study included 2840 diabetic participants and 14,684 nondiabetic participants. Compared with diabetic participants not taking a β-blocker, all-cause mortality was significantly higher in diabetic participants taking any β-blocker (HR, 1.49; 95% CI, 1.09-2.04; P=.01), taking a β₁-selective β-blocker (HR, 1.60; 95% CI, 1.13-2.24; P=.007), or taking a specific β-blocker (bisoprolol, metoprolol, and carvedilol) (HR, 1.55; 95% CI, 1.09-2.21; P=.01). In addition, all-cause mortality in diabetic participants with coronary heart disease (CHD) was significantly higher in those taking beta-blockers, compared with those not taking beta-blockers (HR, 1.64; 95% CI, 1.08-2.48; P=.02), whereas that in non-diabetic participants with CHD was significantly lower in those taking beta-blockers (HR, 0.68; 95% CI, 0.50-0.94; P=.02). A propensity score-matched Cox proportional hazards model yielded similar results.

CONCLUSION

Use of β-blockers may be associated with an increased risk of mortality for patients with diabetes and among the subset who have CHD.

Clinical Events After Discontinuation of β‐Blockers in Patients Without Heart Failure Optimally Treated After Acute Myocardial Infarction

Background:

β-blockers have been among the first medications shown to improve outcomes after acute myocardial infarction (AMI). With the advent of reperfusion therapy and other secondary-prevention medications, their role has become uncertain, and large-scale experience after AMI in the contemporary era is lacking. In particular, the effect of stopping β-blockers in patients initially treated after AMI is unknown.

Methods and Results:

Using the French healthcare databases, 73 450 patients (<80 years of age), admitted for AMI in 2007 to 2012, without acute coronary syndrome (ACS) in the previous 2 years and no evidence of heart failure, having received optimal treatment with myocardial revascularization and all recommended medications in the 4 months after index admission, and not having discontinued β-blockers before 1 year, were followed for 3.8 years on average. β-Blocker discontinuation was defined as 4 consecutive months without exposure. If β-blocker treatment was resumed later on, follow-up was stopped. Both the risk of the composite outcome of death or admission for ACS and the risk of all-cause mortality were assessed in relation with β-blocker discontinuation during follow-up. Adjusted hazard ratios were estimated using marginal structural models accounting for time-varying confounders affected by previous exposure. A similar analysis was performed with statins. Of 204 592 patient-years, 12 002 (5.9%) corresponded to discontinued β-blocker treatment. For β-blocker discontinuation, the adjusted hazard ratio for death or ACS was 1.17 (95% confidence interval, 1.01–1.35); for all-cause death, the adjusted hazard ratio was 1.13 (95% confidence interval, 0.94–1.36). In contrast, for statin discontinuation, the adjusted hazard ratios for death or ACS and for all-cause death were 2.31 (95% confidence interval, 2.01–2.65) and 2.57 (95% confidence interval, 2.19–3.02), respectively.

Conclusions:

In routine care of patients without heart failure, revascularized and optimally treated after AMI, discontinuation of β-blockers beyond 1 year after AMI was associated with an increased risk of death or readmission for ACS, while statistical significance was not reached for the association with all-cause mortality. A contemporary randomized clinical trial is needed to precise the role of β-blockers in the long-term treatment after AMI.

Current use of beta-blockers in patients with coronary artery disease

Beta-blockers have long comprised a cornerstone in the symptomatic treatment of ischemic heart disease and in the secondary prevention of myocardial infarction and heart failure. The majority of studies underlying the evidence of a beneficial effect of beta-blockers on outcomes were conducted more than 25 years ago. In a contemporary era where treatment strategies and secondary prophylactic therapy have undergone several changes, the continued role of beta-blockers in ischemic heart disease has been questioned, especially in the absence of heart failure or a recent myocardial infarction. In summary, few randomized clinical trials are available on the effect of beta-blockers in the reperfusion era, especially on hard endpoints. Likewise, the results of numerous observational studies and meta-analysis are conflicting, emphasizing the need for additional large-scale randomized clinical trials to evaluate the role of beta-blocker therapy in current clinical practice.

β-Blocker Therapy Prior to Admission for Acute Coronary Syndrome in Patients Without Heart Failure or Left Ventricular Dysfunction Improves In-Hospital and 12-Month Outcome: Results From the GULF-RACE 2 (Gulf Registry of Acute Coronary Events-2)

BACKGROUND

The prognostic impact of β-blockers (BB) in acute coronary syndrome (ACS) patients without heart failure (HF) or left ventricular dysfunction is controversial, especially in the postreperfusion era. We sought to determine whether a BB therapy before admission for ACS has a favorable in-hospital outcome in patients without HF, and whether they also reduce 12-month mortality if still prescribed on discharge.

METHODS AND RESULTS

The GULF-RACE 2 (Gulf Registry of Acute Coronary Events-2) is a prospective multicenter study of ACS in 6 Middle Eastern countries. We studied in-hospital cardiovascular events in patients hospitalized for ACS without HF in relation to BB on admission, and 1-year mortality in relation to BB on discharge. Among the 7903 participants, 7407 did not have HF, of whom 5937 (80.15%) patients were on BB. Patients on BB tended to be older and have more comorbidities. However, they had a lower risk of in-hospital mortality, mitral regurgitation, HF, cardiogenic shock, and ventricular tachycardia/ventricular fibrillation. Furthermore, 4208 patients were discharged alive and had an ejection fraction ≥40%. Among those, 84.1% had a BB prescription. At 12 months, they also had a reduced risk of mortality as compared with the non-BB group. Even after correcting for confounding factors in 2 different models, in-hospital and 12-month mortality risk was still lower in the BB group.

CONCLUSIONS

In this cohort of ACS, BB therapy before admission for ACS is associated with decreased in-hospital mortality and major cardiovascular events, and 1-year mortality in patients without HF or left ventricular dysfunction if still prescribed on discharge.

Heart rate recovery of individuals undergoing cardiac rehabilitation after acute coronary syndrome

BACKGROUND

An efficient cardiac rehabilitation programme (CRP) can improve the functional ability of patients after acute coronary syndrome (ACS).

OBJECTIVE

To examine the effect of a CRP on parasympathetic reactivation and heart rate recovery (HRR) measured after a 6-min walk test (6MWT), and correlation with 6MWT distance and well-being after ACS.

METHODS

Eleven normoweight patients after ACS (BMI<25kg/m²; 10 males; mean [SD] age 61 [9] years) underwent an 8-week CRP. Before (pre-) and at weeks 4 (W4) and 8 (W8) during the CRP, they performed a 6MWT on a treadmill, followed by 10-min of seated passive recovery, with HRR and HR variability (HRV) recordings. HRR was measured at 1, 3, 5 and 10min after the 6MWT (HRR1, HRR3, HRR5, HRR10), then modelized by a mono-exponential function. Time-domain (square root of the mean of the sum of the squares of differences between adjacent normal R-R intervals [RMSSD]) and frequency-domain (with high- and low-frequency band powers) were used to analyse HRV. Participants completed a mental and physical well-being questionnaire at pre- and W8. Exhaustion after tests was assessed by the Borg scale. Pearson correlation was used to assess correlations.

RESULTS

HRR3, HRR5 and HRR10 increased by 37%, 36% and 28%, respectively, between pre- and W8 (P<0.05), and were positively correlated with change in 6MWT distance (r=0.58, 0.66 and 0.76; P<0.05). Percentage change in HRR3 was positively correlated with change in well-being (r=0.70; P=0.01). Parasympathic reactivation (RMSSD) was improved only during the first 30sec of recovery (P=0.04).

CONCLUSION

Among patients undergoing a CRP after ACS, increased HRR after a 6MWT, especially at 3min, was positively correlated with 6MWT distance and improved well-being. HRR raw data seem more sensitive than post-exercise HRV analysis for monitoring functional and autonomic improvement after ACS.

Meta-Analysis Comparing Metoprolol and Carvedilol on Mortality Benefits in Patients With Acute Myocardial Infarction

Although carvedilol, a nonselective beta-blocker with alpha-adrenergic blocking and multiple ancillary activities, has been demonstrated to be superior to metoprolol in chronic heart failure, it remains unclear whether the superiority of carvedilol still exists in myocardial infarction (MI). Therefore, we performed a network meta-analysis of randomized controlled trials (RCTs) to compare the 2 drugs in patients with MI. All RCTs that compared either 2 of the following interventions, carvedilol, metoprolol, and placebo, for the treatment of MI were included. The Cochrane Collaboration Central Register of Controlled Trials, Embase, and PubMed were searched thoroughly for potential eligible studies. Finally, 12 RCTs involving 61,081 patients were included. Pooled results showed that compared with placebo, carvedilol and metoprolol significantly reduced composite cardiovascular events (risk ratio [RR] 0.63; 95% credible interval [CrI] 0.41, 0.85 for carvedilol; RR 0.78; 95% CrI 0.65, 0.93 for metoprolol) and re-infarction (RR 0.57; 95% CrI 0.37, 0.84 for carvedilol; RR 0.77; 95% CrI 0.62, 0.91 for metoprolol) in patients with MI. However, neither carvedilol nor metoprolol showed significant benefits on all-cause death, cardiovascular death, revascularization, and rehospitalization. Also, no obvious difference was found when comparing carvedilol and metoprolol on primary or secondary outcomes. In conclusion, there is insufficient evidence supporting the superiority of carvedilol over metoprolol for the treatment of MI. Further studies are needed to confirm our findings.

Benefit of Vasodilating β-Blockers in Patients With Acute Myocardial Infarction After Percutaneous Coronary Intervention: Nationwide Multicenter Cohort Study

BACKGROUND

Although current guidelines recommend β-blocker after acute myocardial infarction (MI), the role of β-blocker has not been well investigated in the modern reperfusion era. In particular, the benefit of vasodilating β-blocker over conventional β-blocker is still unexplored.

METHODS AND RESULTS

Using nation-wide multicenter Korean Acute Myocardial Infarction Registry data, we analyzed clinical outcomes of 7127 patients with acute MI who underwent successful percutaneous coronary intervention with stents and took β-blockers: vasodilating β-blocker (n=3482), and conventional β-blocker (n=3645). In the whole population, incidence of cardiac death at 1 year was significantly lower in the vasodilating β-blocker group (vasodilating β-blockers versus conventional β-blockers, 1.0% versus 1.9%; P=0.003). In 2882 pairs of propensity score-matched population, the incidence of cardiac death was significantly lower in the vasodilating β-blocker group (1.1% versus 1.8%; P=0.028). Although incidences of MI (1.1% versus 1.5%; P=0.277), any revascularization (2.8% versus 3.0%; P=0.791), and hospitalization for heart failure (1.4% versus 1.9%; P=0.210) were not different between the 2 groups, incidences of cardiac death or MI (2.0% versus 3.1%; P=0.010), cardiac death, MI, or hospitalization for heart failure (3.0% versus 4.5%; P=0.003), cardiac death, MI, or any revascularization (3.9% versus 5.3%; P=0.026), and cardiac death, MI, any revascularization, or hospitalization for heart failure (4.8% versus 6.5%; P=0.011) were significantly lower in the vasodilating β-blocker group.

CONCLUSIONS

Vasodilating β-blocker therapy resulted in better clinical outcomes than conventional β-blocker therapy did in patients with acute MI in the modern reperfusion era. Vasodilating β-blockers could be recommended preferentially to conventional ones for acute MI patients.

Reducing the Global Burden of Cardiovascular Disease, Part 2: Prevention and Treatment of Cardiovascular Disease

In this second part of a 2-part series on the global burden of cardiovascular disease, we review the proven, effective approaches to the prevention and treatment of cardiovascular disease. We specifically review the management of acute cardiovascular diseases, including acute coronary syndromes and stroke; the care of cardiovascular disease in the ambulatory setting, including medical strategies for vascular disease, atrial fibrillation, and heart failure; surgical strategies for arterial revascularization, rheumatic and other valvular heart disease, and symptomatic bradyarrhythmia; and approaches to the prevention of cardiovascular disease, including lifestyle factors, blood pressure control, cholesterol-lowering, antithrombotic therapy, and fixed-dose combination therapy. We also discuss cardiovascular disease prevention in diabetes mellitus; digital health interventions; the importance of socioeconomic status and universal health coverage. We review building capacity for conduction cardiovascular intervention through strengthening healthcare systems, priority setting, and the role of cost effectiveness.

National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016

INTRODUCTION

The modern care of suspected and confirmed acute coronary syndrome (ACS) is informed by an extensive and evolving evidence base. This clinical practice guideline focuses on key components of management associated with improved clinical outcomes for patients with chest pain or ACS. These are presented as recommendations that have been graded on both the strength of evidence and the likely absolute benefit versus harm. Additional considerations influencing the delivery of specific therapies and management strategies are presented as practice points.

MAIN RECOMMENDATIONS

This guideline provides advice on the standardised assessment and management of patients with suspected ACS, including the implementation of clinical assessment pathways and subsequent functional and anatomical testing. It provides guidance on the: diagnosis and risk stratification of ACS; provision of acute reperfusion therapy and immediate post-fibrinolysis care for patients with ST segment elevation myocardial infarction; risk stratification informing the use of routine versus selective invasive management for patients with non-ST segment elevation ACS; administration of antithrombotic therapies in the acute setting and considerations affecting their long term use; and implementation of an individualised secondary prevention plan that includes both pharmacotherapies and cardiac rehabilitation. Changes in management as a result of the guideline: This guideline has been designed to facilitate the systematic integration of the recommendations into a standardised approach to ACS care, while also allowing for contextual adaptation of the recommendations in response to the individual's needs and preferences. The provision of ACS care should be subject to continuous monitoring, feedback and improvement of quality and patient outcomes.

Beta Blocker Administration During Emergency Department Evaluation for Acute Coronary Syndrome Is Associated With Lower Posttraumatic Stress Symptoms 1-Month Later

We examined whether beta blocker administration in the emergency department (ED) during evaluation for suspected acute coronary syndrome (ACS) was associated with posttraumatic stress disorder (PTSD) symptoms 1-month later. Participants (N = 350) were enrolled in the Reactions to Acute Care and Hospitalization (REACH) study, an ongoing observational cohort study of ED predictors of medical and psychological outcomes after evaluation for suspected ACS. Beta blockade during evaluation in the ED was extracted from medical records, and PTSD symptoms in response to the experience of suspected ACS were assessed 1-month later via telephone. Beta blockade in the ED was associated with lower PTSD symptoms 1-month later, b = -2.80, β = -.09, p = .045, after adjustment for demographics, preexisting psychological and medical covariates, and participants' distress during ED evaluation. Despite small effects, findings suggest that beta blockade during ED evaluation for suspected ACS-a time period relevant to fear consolidation of the memory of this potentially life-threatening event-may have protective effects for later psychological health.

Evidence of potential bias in a comparison of β blockers and calcium channel blockers in patients with chronic obstructive pulmonary disease and acute coronary syndrome: results of a multinational study

OBJECTIVES

A number of observational studies have reported that, in patients with chronic obstructive pulmonary disease (COPD), β blockers (BBs) decrease risk of mortality and COPD exacerbations. To address important methodological concerns of these studies, we compared the effectiveness and safety of cardioselective BBs versus non-dihydropyridine calcium channel blockers (non-DHP CCBs) in patients with COPD and acute coronary syndromes (ACS) using a propensity score (PS)-matched, active comparator, new user design. We also assessed for potential unmeasured confounding by examining a short-term COPD hospitalisation outcome.

SETTING AND PARTICIPANTS

We identified 22 985 patients with COPD and ACS starting cardioselective BBs or non-DHP CCBs across 5 claims databases from the USA, Italy and Taiwan.

PRIMARY AND SECONDARY OUTCOME MEASURES

Stratified Cox regression models were used to estimate HRs for mortality, cardiovascular (CV) hospitalisations and COPD hospitalisations in each database after variable-ratio PS matching. Results were combined with random-effects meta-analyses.

RESULTS

Cardioselective BBs were not associated with reduced risk of mortality (HR, 0.90; 95% CI 0.78 to 1.02) or CV hospitalisations (HR, 1.06; 95% CI 0.91 to 1.23), although statistical heterogeneity was observed across databases. In contrast, a consistent, inverse association for COPD hospitalisations was identified across databases (HR, 0.54; 95% CI 0.47 to 0.61), which persisted even within the first 30 days of follow-up (HR, 0.55; 95% CI 0.37 to 0.82). Results were similar across a variety of sensitivity analyses, including PS trimming, high dimensional-PS matching and restricting to high-risk patients.

CONCLUSIONS

This multinational study found a large inverse association between cardioselective BBs and short-term COPD hospitalisations. The persistence of this bias despite state-of-the-art pharmacoepidemiologic methods calls into question the ability of claims data to address confounding in studies of BBs in patients with COPD.

Secondary preventive medication use in a prevalent population-based cohort of acute coronary syndrome survivors

AIM

Describe the dispensing patterns for guideline-recommended medications during 2008 in people with acute coronary syndrome (ACS) and how dispensing varies by gender and time since last ACS hospitalization.

METHOD

A descriptive cohort spanning 20 years of people alive post-ACS in 2008. We extracted all ACS hospitalizations and deaths in Western Australia (1989-2008), and all person-linked Pharmaceutical Benefits Scheme claims nationally for 2008. Participants were 23 642 men and women (36.8%), alive and aged 65-89 years in mid-2008 who were hospitalized for ACS between 1989 and 2008. Main outcome was the proportion of the study cohort (in 2008) dispensed guideline-recommended cardiovascular medications in that year. Adjusted odds ratios estimating the association between type (and number) of guideline-recommended medications and time since last ACS hospitalization.

RESULTS

Medications most commonly dispensed in 2008 were statins (79.6% of study cohort) and then angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers (ACEi/ARBs) (71.1%), aspirin or clopidogrel (59.4%), and β-blockers (54.6%). Only 51.8% of the cohort was dispensed three or more of these drug types in 2008. Women with ACS were 18% less likely to be dispensed statins (adjusted odds ratio (OR)=0.82; 95% CI 0.76-0.88). Overall, for each incremental year since last ACS admission, there was an 8% increased odds (adjusted OR=1.08; 95% CI 1.07-1.08) of being dispensed fewer of the recommended drug regimen in 2008.

CONCLUSION

Longer time since last ACS admission was associated with dispensing fewer medications types and combinations in 2008. Interventions are warranted to improve dispensing long term and any apparent gender inequality in the drug class filled.