Re-evaluation of the cardioprotective effects of cannabinoids against ischemia-reperfusion injury according to the IMproving Preclinical Assessment of Cardioprotective Therapies (IMPACT) criteria

Ischemic heart disease, associated with high morbidity and mortality, represents a major challenge for the development of drug-based strategies to improve its prognosis. Results of pre-clinical studies suggest that agonists of cannabinoid CB2 receptors and multitarget cannabidiol might be potential cardioprotective strategies against ischemia-reperfusion injury. The aim of our study was to re-evaluate the cardioprotective effects of cannabinoids against ischemia-reperfusion injury according to the IMproving Preclinical Assessment of Cardioprotective Therapies (IMPACT) criteria published recently by the European Union (EU) CARDIOPROTECTION COST ACTION. To meet the minimum criteria of those guidelines, experiments should be performed (i) on healthy small animals subjected to ischemia with reperfusion lasting for at least 2 hours and (ii) confirmed in small animals with comorbidities and co-medications and (iii) in large animals. Our analysis revealed that the publications regarding cardioprotective effects of CB2 receptor agonists and cannabidiol did not meet all three strict steps of IMPACT. Thus, additional experiments are needed to confirm the cardioprotective activities of (endo)cannabinoids mainly on small animals with comorbidities and on large animals. Moreover, our publication underlines the significance of the IMPACT criteria for a proper planning of preclinical experiments regarding cardiac ischemia-reperfusion injury.

Acute Coronary Syndrome

One percent of primary care visits are due to chest pain. It is critical for the primary care physician to have a high index of suspicion for acute coronary syndrome and understand the management of this important condition. This article reviews the outpatient evaluation and management of chest pain and summarizes the key points of inpatient evaluation and treatment of acute coronary syndrome.

The Effect of Beta-Blocker Post-Myocardial Infarction With Ejection Fraction >40% Pooled Analysis From Seven Arabian Gulf Acute Coronary Syndrome Registries

The use of beta-blockers (BB) in reduced left ventricular ejection fraction (LVEF) post-myocardial infarction (MI) is associated with reduced 1-year mortality, while their role in patients with mid-range and preserved LVEF post-MI remains controversial. We studied 31,620 patients who presented with acute coronary syndrome (ACS) enrolled in seven Arabian Gulf registries between 2005 and 2017. Patients with LVEF ≤40% were excluded. The remaining cohort was divided into two groups: BB group (n = 15,541) and non-BB group (n = 2,798), based on discharge medications. Patients in the non-BB group were relatively younger (55.3 vs. 57.4, P = .004) but higher risk at presentation; with higher Global Registry of Acute Coronary Events (GRACE) score (119.2 vs 109.2, P < .001), higher percentage of cardiogenic shock (3.5 vs 1.4%, P < .001), despite lower prevalence of comorbidities, such as hypertension and hyperlipidemia. BB use was associated with lower 1-year mortality in a multivariate logistic regression analysis, adjusting for major confounders [adjusted odds ratio (OR): 0.71 (95% CI 0.51-0.99)]. This remained the case in a sensitivity analysis using propensity score matching [adjusted OR: 0.34 (95% CI 0.16-0.73)]. In this study, using Arabian Gulf countries registries, the use of BB after ACS with LVEF >40% was independently associated with lower 1-year mortality.

Impact of guideline-directed medical therapy on 5-year mortality in patients with newly diagnosed peripheral artery disease

OBJECTIVE

Current guidelines recommend that patients with peripheral artery disease (PAD) should be treated with antithrombotic agents, renin-angiotensin-system blockers, and statins. However, the clinical impact of guideline-directed medical therapy (GDMT) on long-term mortality in patients with newly diagnosed PAD remains unclear. We aimed to investigate the prevalence of GDMT and evaluate 5-year mortality according to GDMT after PAD diagnosis.

METHODS

This retrospective cohort study, using nationwide health insurance claims data in Korea, included patients newly diagnosed with PAD between 2006 and 2015. GDMT was defined as the use of all drugs, including antithrombotic agents, renin-angiotensin-system blockers, and statins, within 3 months of PAD diagnosis. The primary endpoint was all-cause mortality.

RESULTS

We investigated 19,561 newly diagnosed patients with PAD without proven cardiovascular disease. Among the study population, 4378 patients (22.4%) were categorized in the GDMT and 15,183 (77.6%) in the non-GDMT groups. During the 5-year follow-up, GDMT showed a lower incidence of all-cause mortality than that of non-GDMT (2.8% vs 4.8%; adjusted hazard ratio, 0.329; 95% confidence interval, 0.257-0.421; P < .001). Even in the propensity-matched population, GDMT showed a lower mortality rate than non-GDMT (hazard ratio, 0.283; 95% confidence interval, 0.217-0.370; P < .001). As the number of guideline-recommended drugs increased, the mortality rate decreased proportionately.

CONCLUSIONS

After PAD diagnosis, GDMT was associated with a lower incidence of mortality regardless of proven cardiovascular disease. This retrospective analysis showed an insufficient prevalence of GDMT among patients with PAD in real-world practice.

Impact of Optimal Medical Therapy on Long-Term Outcomes After Myocardial Revascularization for Multivessel Coronary Disease

Although optimal medical therapy (OMT) after coronary revascularization is advocated for intensive secondary prevention, its criteria and effect on long-term outcomes are uncertain. Using data from the ASAN-Multivessel (Asan Medical Center-Multivessel Revascularization) registry, we identified 8,311 patients who underwent coronary artery bypass grafting (CABG) (n = 3,115) or percutaneous coronary intervention (PCI) (n = 5,196). OMT was defined as the combination of minimum of 3 medications in 4 drug classes (antiplatelet drugs, statins, β blockers, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers). Two primary outcomes were all-cause mortality and serious composite outcome of death, spontaneous myocardial infarction, or stroke at 10 years. Of 8,311 patients, 4,321 (52.0%) followed OMT. In the 3,397 propensity-score-matched cohort, OMT status compared with non-OMT status was significantly associated with a lower risk of all-cause mortality (10.7% vs 18.7%; hazard ratio [HR] 0.55, 95% confidence interval [CI] 0.47 to 0.65) and serious composite outcome (14.5% vs 22.5%, HR 0.635, 95% CI 0.55 to 0.73) at 10 years. The association on 10-year mortality was more prominent in the PCI group (HR 0.45, 95% CI 0.36 to 0.56) than in the CABG group (HR 0.72, 95% CI 0.58 to 0.90) with a significant interaction (p = 0.001). Overall findings were consistent using different OMT criteria (all 4 types of medications). In conclusion, OMT significantly lowered the risks of mortality and major cardiovascular events at 10 years in patients with multivessel revascularization. The OMT impact on mortality was more remarkable in the PCI group than in the CABG group. This work was registered at http://ClinicalTrials.gov (Identifier: NCT02039752).

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Beta-blocker therapy in patients with acute myocardial infarction: not all patients need it

Most of the evidences for beneficial effects of beta-blockers in patients with acute myocardial infarction (AMI) were from the clinical studies published in the pre-reperfusion era when anti-platelet drugs, statins or inhibitors of renin-angiotensin-aldosterone system which are known to reduce cardiovascular mortality of patients with AMI were not introduced. In the reperfusion era, beta-blockers' benefit has not been clearly shown except in patients with reduced ejection fraction (EF; ≤40%). In the era of the early reperfusion therapy for AMI, a number of patients with mildly reduced EF (>40%, <50%) or preserved EF (≥50%) become increasing. However, because no randomized clinical trials are available until now, the benefit and the optimal duration of oral treatment with beta-blockers in patients with mildly reduced or preserved EF are questionable. Registry data have not showed the association of oral beta-blocker therapy with decreased mortality in survivors without heart failure or left ventricular systolic dysfunction after AMI. In the Korea Acute Myocardial Infarction Registry-National Institute of Health of in-hospital survivors after AMI, the benefit of beta-blocker therapy at discharge was shown in patients with reduced or mildly reduced EF, but not in those with preserved EF, which provides new information about beta-blocker therapy in patients without reduced EF. However, clinical practice can be changed when the results of appropriate randomized clinical trials are available. Ongoing clinical trials may help to answer the unresolved issues of beta-blocker therapy in patients with AMI.

Comparative Effectiveness of Long-Term Maintenance Beta-Blocker Therapy After Acute Myocardial Infarction in Stable, Optimally Treated Patients Undergoing Percutaneous Coronary Intervention

Background The benefits of long-term maintenance beta-blocker (BB) therapy in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) have not been well established. Methods and Results Using the Korean nationwide registry, a total of 7159 patients with AMI treated with PCI who received BBs at discharge and were free from death or cardiovascular events for 3 months after PCI were included in the analysis. Patients were divided into 4 groups according to BB maintenance duration: <12 months, 12 to <24 months, 24 to <36 months, and ≥36 months. The primary outcome was the composite of all-cause death, recurrent MI, heart failure, or hospitalization for unstable angina. During a mean 5.0±2.8 years of follow-up, over half of patients with AMI (52.5%) continued BB therapy beyond 3 years following PCI. After propensity score matching and propensity score marginal mean weighting through stratification, a stepwise inverse correlation was noted between BB duration and risk of the primary outcome (<12 months: hazard ratio [HR], 2.19 [95% CI, 1.95-2.46]; 12 to <24 months: HR, 2.10 [95% CI, 1.81-2.43];, and 24 to <36 months: HR, 1.68 [95%CI, 1.45-1.94]; reference: ≥36 months). In a 3-year landmark analysis, BB use for <36 months was associated with an increased risk of the primary outcome (adjusted HR, 1.59 [95% CI, 1.37-1.85]) compared with BB use for ≥36 months. Conclusions Among stabilized patients with AMI following PCI, longer maintenance BB therapy, especially for >36 months, was associated with better clinical outcomes. These findings might imply that a better prognosis can be expected if patients with AMI maintain BB therapy for ≥36 months after PCI. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02806102.

Association of beta-blockers beyond 1 year after myocardial infarction and cardiovascular outcomes

OBJECTIVE

Beta-blockers (BB) are an established treatment following myocardial infarction (MI). However, there is uncertainty as to whether BB beyond the first year of MI have a role in patients without heart failure or left ventricular systolic dysfunction (LVSD).

METHODS

A nationwide cohort study was conducted including 43 618 patients with MI between 2005 and 2016 in the Swedish register for coronary heart disease. Follow-up started 1 year after hospitalisation (index date). Patients with heart failure or LVSD up until the index date were excluded. Patients were allocated into two groups according to BB treatment. Primary outcome was a composite of all-cause mortality, MI, unscheduled revascularisation and hospitalisation for heart failure. Outcomes were analysed using Cox and Fine-Grey regression models after inverse propensity score weighting.

RESULTS

Overall, 34 253 (78.5%) patients received BB and 9365 (21.5%) did not at the index date 1 year following MI. The median age was 64 years and 25.5% were female. In the intention-to-treat analysis, the unadjusted rate of primary outcome was lower among patients who received versus not received BB (3.8 vs 4.9 events/100 person-years) (HR 0.76; 95% CI 0.73 to 1.04). Following inverse propensity score weighting and multivariable adjustment, the risk of the primary outcome was not different according to BB treatment (HR 0.99; 95% CI 0.93 to 1.04). Similar findings were observed when censoring for BB discontinuation or treatment switch during follow-up.

CONCLUSION

Evidence from this nationwide cohort study suggests that BB treatment beyond 1 year of MI for patients without heart failure or LVSD was not associated with improved cardiovascular outcomes.

Effectiveness and Tolerability of Bisoprolol/Perindopril Single-Pill Combination in Patients with Arterial Hypertension and a History of Myocardial Infarction: The PRIDE Observational Study

INTRODUCTION

This study assessed the real-life effectiveness of a single-pill combination (SPC) of bisoprolol/perindopril for controlling blood pressure (BP) and symptoms of angina in patients with hypertension and a history of myocardial infarction (MI).

METHODS

Eligible patients with arterial hypertension and a history of MI were aged 18-79 years and had initiated bisoprolol/perindopril SPC within 3 months of study enrollment as part of routine Russian clinical practice. The primary endpoint was mean change in systolic and diastolic BP (SBP/DBP) at week 12 compared with baseline (data collected retrospectively). Secondary endpoints were assessed at weeks 4 and 12 and included mean change in resting heart rate (HR), proportion of patients reaching target level of resting HR, antianginal effectiveness of the SPC, and proportion of patients reaching target BP levels.

RESULTS

A total of 504 patients were enrolled, of whom 481 comprised the full analysis set (mean age 61.4 ± 8.9 years, 68% men). Mean baseline SBP/DBP and HR values were 148.9 ± 16.8/87.7 ± 11.0 mmHg and 77.4 ± 10.5 bpm, respectively. Mean durations of hypertension and CAD were 12.8 ± 8.4 and 6.1 ± 6.3 years, respectively, and time since MI was 3.8 ± 5.3 years. At week 12, SBP/DBP had decreased by 24.9/12.2 mmHg (P < 0.001 vs baseline). Target BP (< 140/90 mmHg) was achieved by 69.8% and 95.9% of patients at weeks 4 and 12, respectively, and target HR (55-60 bpm) by 17.3% and 34.5% at weeks 4 and 12 versus 3.1% at baseline (P < 0.001). Reductions in angina attacks, nitrate consumption, and improvements in HR were statistically significant. Treatment was well tolerated.

CONCLUSION

Treatment of symptomatic patients with CAD, hypertension, and a history of MI with a bisoprolol/perindopril SPC was associated with significant decreases in SBP/DBP and a high proportion of patients achieving BP treatment goals. This was accompanied by improvements in angina symptoms and reductions in HR in a broad patient population representative of those seen in everyday clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT04656847.

Evidence-Based Optimal Medical Therapy and Mortality in Patients With Acute Myocardial Infarction After Percutaneous Coronary Intervention

Background The secondary prevention with pharmacologic therapy is essential for preventing recurrent cardiovascular events in patients experiencing acute myocardial infarction. Guideline-based optimal medical therapy (OMT) for patients with acute myocardial infarction consists of antiplatelet therapy, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, β-blockers, and statins. We aimed to determine the prescription rate of OMT use at discharge and to evaluate the impact of OMT on long-term clinical outcomes in patients with acute myocardial infarction who underwent percutaneous coronary intervention in the drug-eluting stent era using nationwide cohort data. Methods and Results Using the National Health Insurance claims data in South Korea, patients with acute myocardial infarction who had undergone percutaneous coronary intervention with a drug-eluting stent between July 2013 and June 2017 were enrolled. A total of 35 972 patients were classified into the OMT and non-OMT groups according to the post-percutaneous coronary intervention discharge medication. The primary end point was all-cause death, and the 2 groups were compared using a propensity-score matching analysis. Fifty-seven percent of patients were prescribed OMT at discharge. During the follow-up period (median, 2.0 years [interquartile range, 1.1-3.2 years]), OMT was associated with a significant reduction in the all-cause mortality (adjusted hazard ratio [aHR], 0.82 [95% CI, 0.76-0.90]; P<0.001) and composite outcome of death or coronary revascularization (aHR, 0.89 [95% CI, 0.85-0.93]; P<0.001). Conclusions OMT was prescribed at suboptimal rates in South Korea. However, our nationwide cohort study showed that OMT has a benefit for long-term clinical outcomes on all-cause mortality and composite outcome of death or coronary revascularization after percutaneous coronary intervention in the drug-eluting stent era.

Curcumin analogue C66 ameliorates mouse cardiac dysfunction and structural disorders after acute myocardial infarction via suppressing JNK activation

Myocardial infarction contributes to the development of cardiovascular disease, and leads to severe inflammation and health hazards. Our previous studies identified C66, a novel curcumin analogue, had pharmacological benefits in suppressing tissue inflammation. Therefore, the present study hypothesized C66 might improve cardiac function and attenuate structural remodeling after acute myocardial infarction. Administration of 5 mg/kg C66 for 4-week significantly improved cardiac function and decreased infarct size after myocardial infarction. C66 also effectively reduced cardiac pathological hypertrophy and fibrosis in non-infarct area. In vitro H9C2 cardiomyocytes, C66 also exerted the pharmacological benefits of anti-inflammatory and anti-apoptosis under hypoxic conditions Mechanistically, C66 inhibited cardiac inflammation and cardiomyocyte apoptosis by targeting on JNK phosphorylation, whereas replenishment of JNK activation abolished the cardioprotective benefits of C66 treatment. Taken together, curcumin analogue C66 inhibited the activation of JNK signaling, and possessed pharmacological benefits in alleviating myocardial infarction-induced cardiac dysfunction and pathological tissue injuries.

βeta blocker interruption after uncomplicated myocardial infarction: rationale and design of the randomized ABYSS trial

BACKGROUND

The long-term use of β-blocker after myocardial infarction (MI) when global left ventricular ejection fraction (LVEF) is preserved has not been studied in the era of modern myocardial reperfusion and secondary prevention therapies. It is unknown whether β-blockers are useful in stable post-MI patients without reduced LVEF and without heart failure.

METHODS

The Assessment of β-blocker interruption 1 Year after an uncomplicated myocardial infarction on Safety and Symptomatic cardiac events requiring hospitalization (ABYSS) Trial enrolled in 49 centers in France, 3,700 patients with a prior (>6 months) history of MI and a LVEF >40%, chronically treated with a β-blocker and without any major cardiovascular event (MACE) in the past 6 months. These patients were randomized to interruption or continuation of their β-blocker therapy. The primary objective is to demonstrate the noninferiority of interruption vs continuation of the β-blocker therapy on the primary composite endpoint of all-cause death, stroke, MI, hospitalization for any cardiovascular reason at the end of follow-up (accrual follow-up) with a one-year minimum follow-up for the last randomized patient. Secondary objectives will focus on patient reported outcomes with the evaluation of the quality of life before and after randomization with the EQ5D-5L questionnaire. Enrolment has been completed.

CONCLUSION

The ABYSS trial evaluates the cardiovascular safety of β-blocker interruption in stabilized post-MI patients without heart failure nor reduced LVEF. ABYSS trial is a reappraisal of β-blockers life-long therapy in stable post-MI patients without reduced LVEF.

CLINICAL TRIAL REGISTRATION

NCT03498066 (clinicaltrials.gov).

Moderate-Intensity Statins Plus Ezetimibe vs. High-Intensity Statins After Coronary Revascularization: A Cohort Study

PURPOSE

Whether moderate-intensity statins plus ezetimibe could be an alternative to high-intensity statins in patients with atherosclerotic cardiovascular disease is unclear. We compared the risk of adverse cardiovascular events in patients receiving moderate-intensity statins plus ezetimibe vs. high-intensity statins after a coronary revascularization procedure using data from a large cohort study.

METHOD

Population-based cohort study using nationwide medical insurance data from Korea. Study participants (n = 20,070) underwent percutaneous coronary intervention or coronary artery bypass graft surgery between January 1, 2015, and December 31, 2016, and received moderate-intensity statins (atorvastatin 10-20 mg or rosuvastatin 5-10 mg) plus ezetimibe (n = 922) or high-intensity statins (atorvastatin 40-80 mg or rosuvastatin 20 mg; n = 19,148). The primary outcome was a composite of cardiovascular mortality, hospitalization for myocardial infarction (MI), hospitalization for stroke, or revascularization.

RESULTS

At 12 months, the incidence rates of the primary outcome were 138.0 vs. 154.0 per 1000 person-years in the moderate-intensity stains plus ezetimibe and the high-intensity statins group, respectively. The fully adjusted hazard ratio [HR] for the primary outcome was 1.11 (95% confidence interval [CI] 0.86-1.42; p = 0.43). The multivariable-adjusted HR for a composite of cardiovascular mortality, hospitalization for MI, or hospitalization for stroke was 1.05 (95% CI 0.74-1.47; p = 0.80). During follow-up, the proportion of patients maintaining their initial lipid-lowering therapy was significantly higher in the moderate-intensity statins plus ezetimibe group than in the high-intensity statins group.

CONCLUSIONS

Patients undergoing a coronary revascularization procedure who received moderate-intensity statins plus ezetimibe showed similar rates of major adverse cardiovascular events as patients who received high-intensity statins.

Treatment strategies of acute myocardial infarction: updates on revascularization, pharmacological therapy, and beyond

Owing to recent advances in early reperfusion strategies, pharmacological therapy, standardized care, and the identification of vulnerable patient subsets, the prognosis of acute myocardial infarction has improved. However, there is still considerable room for improvement. This review article summarizes the latest evidence concerning clinical diagnosis and treatment of acute myocardial infarction.

Effects of β-blockers on all-cause mortality in patients with diabetes and coronary heart disease: A systematic review and meta-analysis

Beta-blockers have been considered as an effective treatment in secondary prevention of coronary heart disease (CHD). However, there is still disputed whether β-blockers can increase all-cause mortality in patients with coronary heart disease and diabetes mellitus (DM). Here, our systematic review and meta-analysis is aiming to assess the effects of β-blockers on all-cause mortality in patients with coronary heart disease and diabetes mellitus. Four databases (PubMed, Embase, Cochrane Library and Web of Science) and other sources were searched to collect randomized controlled trials (RCTs) and cohort studies related to the treatment of β-blockers for coronary heart disease and diabetes mellitus patients. We further evaluated quality of evidence using the grading of recommendations assessment, development, and evaluation (GRADE) approach. Finally, a total of 16,188 records were identified, and four randomized controlled trials and six cohort studies (206,490 patients) were included. Random effects analysis revealed that β-blockers combined with routine treatment (RT) significantly decreased all-cause mortality in patients with coronary heart disease and diabetes mellitus compared with RT in control group (RR 0.59, 95% CI 0.47 to 0.75; p < 0.000 01; I² = 72%). Subgroup analysis of all-cause mortality by the subtype of diabetes mellitus and definite MI patients (RR 0.54, 95% CI 0.45 to 0.65, p < 0.000 01, I² = 29%) and the subtype of randomized controlled trials (RR 0.49, 95% CI 0.32 to 0.76, p = 0.001, I² = 0%) indicated a relatively small heterogeneity and stable results. β-blockers application significantly reduced cardiovascular death as well (RR 0.56, 95% CI 0.42 to 0.74; p < 0.000 1; I² = 0%). Our meta-analysis provided critical evidence of β-blockers treatment for patients with coronary heart disease (especially MI type) and diabetes mellitus, and discussed the advantages and potential metabolic risks for the clinical use of β-blockers. This study suggested that β-blockers application may improve all-cause mortality and cardiovascular death in coronary heart disease (especially MI type) and diabetes mellitus patients. However, given a small number of included studies, the aforementioned conclusion should be confirmed in a multi-center, large-scale, and strictly designed trial.

The Prognostic Value of the Triglyceride Glucose Index in Patients With Acute Myocardial Infarction

Objective: The triglyceride-glucose (TyG) index is a simple and reliable surrogate for insulin resistance. Recent studies have suggested that the TyG index is an independent predictor of cardiovascular disease. However, the prognostic value of the TyG index in patients with acute myocardial infarction (AMI) remains uncertain. Thus, this study aimed to evaluate the prognostic value of the TyG index in patients with AMI. Methods: AMI patients admitted to Zhongda Hospital from 2018 to 2020 were successively enrolled. After screening the inclusion criteria, 1144 patients were divided into three groups according to the tertiles of the TyG index distribution. Patients were followed up for 1 year as outpatients or contacted via telephone, and the occurrence and timing of all-cause deaths were recorded. Results: The TyG index was significantly correlated with heart failure (HF) in AMI patients. Patients with a high TyG index (group 3) (odds ratio: 9.070, 95% confidence interval [CI] 4.359-18.875, P＜.001) had a significantly higher incidence of HF compared with patients with median TyG index (group 2). Similarly, the incidence of all-cause death in group 3 was significantly higher than that in group 2 during the 1-year follow-up (hazard ratio: 2.996, 95% CI 1.058-8.487, P = .039). Conclusion: The TyG index is closely related to HF and may be a valuable indicator to predict the long-term prognosis of patients with AMI.

Beta-blocker prescription and outcomes in uncomplicated acute myocardial infarction: Insight from the ePARIS registry

BACKGROUND

Systematic prescription of beta-blockers after myocardial infarction remains an open question in the era of revascularization, especially for patients with uncomplicated myocardial infarction.

OBJECTIVE

To evaluate in a real-life registry the proportion of patients with uncomplicated myocardial infarction (preserved left ventricular ejection fraction and no cardiovascular event within the first 6 months), and to report their characteristics, outcomes and beta-blocker use.

METHODS

We included 1887 consecutive patients with ST-segment elevation myocardial infarction from the prospective ePARIS registry. Patients were divided into three groups: the "uncomplicated myocardial infarction" group (n=1060), defined by a left ventricular ejection fraction ≥ 40% and a 6-month period free from cardiovascular events; the "complicated myocardial infarction" group (n=366), defined by a left ventricular ejection fraction ≥ 40% and a recurrent cardiovascular event in the first 6 months; and the "left ventricular dysfunction" group (n=461), defined by a left ventricular ejection fraction<40%.

RESULTS

During a median follow-up of 2.7 years (interquartile range 1.0-4.9 years), the "uncomplicated myocardial infarction" group was at low mortality risk compared with the "complicated myocardial infarction" group (hazard ratio 0.38, 95% confidence interval 0.25-0.58; P<0.01) and the "left ventricular dysfunction" group (hazard ratio 0.22, 95% confidence interval 0.15-0.32; P<0.01). Beta-blockers were prescribed at discharge predominantly in the "uncomplicated myocardial infarction" group (93%) compared with 87% in the "complicated myocardial infarction" group and 81% in the "left ventricular dysfunction" group.

CONCLUSIONS

Beta-blockers are less prescribed in patients who may need them the most. The benefit of beta-blockers-largely prescribed in lower-risk patients-remains to be shown beyond the first 6 months for these patients with no left ventricular dysfunction and no recurrent events.

Clinical impact of beta-blockers at discharge on long-term clinical outcomes in patients with non-reduced ejection fraction after acute myocardial infarction

BACKGROUND

Beta-blockers are associated with several clinical benefits in patients with reduced left ventricular ejection fraction (REF) after acute myocardial infarction (AMI), such as lower rates of mortality, recurrence of myocardial infarction, and heart failure. However, the long-term prognosis of beta-blockers has rarely been investigated in patients with non-REF after AMI. This study aimed to investigate the clinical benefits of beta-blockers in these patients.

METHODS

A total of 3281 consecutive patients who were hospitalized within 48 h after AMI were registered in the J-MINUET study. Patients who underwent primary percutaneous coronary intervention (PCI) and had a left ventricular ejection fraction ≥40 % were enrolled, and patients who died during admission were excluded. Included patients were divided into two groups according to the prescription of beta-blockers at discharge. Their characteristics and clinical outcomes were compared.

RESULTS

The number of AMI patients treated with beta-blockers was 1353 (70.4 %). Patients who received beta-blockers were younger and had a higher incidence of hypertension, dyslipidemia, and ST-segment elevation myocardial infarction than those who did not receive beta-blockers. The peak creatine kinase level after primary PCI was significantly higher in patients who received beta-blockers. These patients also had a lower incidence of a composite of all-cause death, myocardial infarction, and stroke compared to those that did not receive beta-blockers (7.3 % vs. 11.9 %, p = 0.001). Multivariate analysis showed that beta-blocker use was an independent factor for better clinical outcomes.

CONCLUSIONS

The J-MINUET study revealed the clinical benefit of beta-blockers in AMI patients with non-REF after primary PCI.

Association of beta-blocker therapy at discharge with clinical outcomes in patients without heart failure or left ventricular systolic dysfunction after acute coronary syndrome: An updated systematic review and meta-analysis

BACKGROUND

Beta-blockers are the standard treatment for acute coronary syndrome (ACS) based on evidence from the prethrombolytic era. We sought to examine the effect of beta-blocker treatment on patients without heart failure or left ventricular systolic dysfunction after ACS in the contemporary percutaneous coronary intervention (PCI) era.

METHODS

We systematically searched PubMed, Web of Science, Cochrane Library, ClinicalTrials.gov and Google Scholar for studies comparing beta-blockers versus no beta-blockers in ACS patients in the contemporary PCI era. The primary outcome was all-cause death. Pooling unadjusted and multivariable adjusted results were calculated under random-effects models.

RESULTS

Data from 15 studies (n=205,672), including 1 randomized trial, were analysed. Compared with no beta-blockers, beta-blocker therapy at discharge may reduce the risk of all-cause death (odds ratio [OR] 0.66, 95% confidence interval [CI]: 0.50-0.86; I²=81.9%). Subgroup analysis according to single or multicentre studies indicated similar results. Prospective studies suggested that all-cause death was less common in the beta-blocker group. After multivariable adjustment, a lower risk of all-cause death was still observed with beta-blockers (OR: 0.74, 95% CI: 0.59-0.94; I²=40.1%). No differences existed in major adverse cardiovascular events (MACE), cardiac death, myocardial infarction, heart failure, revascularization or stroke, before and after multivariable adjustment.

CONCLUSIONS

In patients without heart failure or left ventricular systolic dysfunction after ACS in the contemporary PCI era, beta-blocker therapy may still be beneficial due to a potential reduced risk of all-cause death.

Prolonged dual antiplatelet therapy after drug-eluting stent implantation in patients with diabetes mellitus: A nationwide retrospective cohort study

Background

Optimal duration of dual antiplatelet therapy (DAPT) in patients with diabetes mellitus (DM) who have undergone drug-eluting stent (DES) implantation is not clearly established. This study sought to impact of DAPT duration on real-world clinical outcome in patients with or without DM.

Methods

Using a nationwide cohort database, we investigate the association between DAPT duration and clinical outcome between 1 and 3 years after percutaneous coronary intervention (PCI). Primary outcome was all-cause death. Secondary outcomes were cardiovascular death, myocardial infarction, and composite bleeding events. After weighting, 90,100 DES-treated patients were included; 29,544 patients with DM and 60,556 without DM; 31,233 patients with standard DAPT (6–12 months) and 58,867 with prolonged DAPT (12–24 months).

Results

The incidence of all-cause death was significantly lower in patients with prolonged DAPT [8.3% vs. 10.5% in those with standard DAPT, hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.72–0.84] in diabetic patients and non-diabetic patients (4.5% vs. 5.0% in those with standard DAPT, HR 0.89, 95% CI 0.83–0.96). The incidence of composite bleeding events was 5.7% vs. 5.4%, respectively, (HR 1.07, 95% CI 0.96–1.18) in diabetic patients and 5.6% vs. 5.0%, respectively, in non-diabetic patients (HR 1.13, 95% CI 1.05–1.21). There was a significant interaction between the presence of DM and DAPT duration for all-cause death (p for interaction, p_int = 0.01) that further favored prolonged DAPT in diabetic patients. However, there was no significant interaction between the presence of DM and DAPT duration for composite bleeding events (p_int = 0.38).

Conclusions

This study showed that prolonged rather than standard DAPT might be clinically beneficial in diabetic patients with DES implantation.

Trial registration

ClinicalTrial.gov (NCT04715594).

Effects of Dapagliflozin in Combination with Metoprolol Sustained-Release Tablets on Prognosis and Cardiac Function in Patients with Acute Myocardial Infarction after PCI

Objective

To find the effects of dapagliflozin in combination with metoprolol sustained-release tablets on cardiac function and prognosis in acute myocardial infarction patients after PCI.

Methods

A total of 84 patients with myocardial infarction who experienced PCI from February 2020 to February 2022 were included and allocated into 3 groups: groups A, B, and C (n = 28/per group). Group A was given dapagliflozin combined with metoprolol sustained-release tablets, group B was given dapagliflozin, and group C was given the placebo. Left ventricular end diastolic diameter (EDD), left ventricular ejection fraction (LVEF), and end systolic diameter (ESD) were measured before and after treatment in all groups; myocardial infarction areas were matched among all three groups at 3 months posttreatment. The serum concentrations of interleukin-6 (IL-6), hypersensitive C-reactive protein (hs-CRP), superoxide dismutase (SOD), and malondialdehyde (MDA) were detected in all three groups before and after treatment. The levels of N-terminal probrain natriuretic peptide (NT-pro BNP), lipoprotein (a) (Lp(a)), ischemia-modified albumin (IMA), and secreted frizzled-related protein 5 (SFRP5) were also detected in the serum of all groups. Adverse reactions and cardiovascular adverse events were matched between all groups.

Results

The levels of LVEF in groups A and B were increased after treatment, while the levels of EDD and ESD were decreased. The improvement degree of LVEF and EDD levels in groups A and B was found greater compared to group C (P < 0.05). No significant difference was found in myocardial infarction area among the three groups at 3 months postoperation (P > 0.05). Serum concentrations of MDA, hs-CRP, IL-6, IMA, NT-proBNP, and Lp(a) were found to decrease in all three groups after treatment, while the levels of SOD and SFRP5 were increased. The improvement degree of serum hs-CRP, IL-6, SOD, MDA, IMA, NT-proBNP, Lp(a), and SFRP5 levels was greater in both groups A and B compared to group C. The improvement degree of serum hS-CRP, SOD, MDA, IMA, Nt-probNP, Lp(a), and SFRP5 levels was significantly greater in group A compared to group B (P < 0.05). No adverse effect was observed in all three groups (P > 0.05). Total occurrence of cardiovascular adverse effects such as stent thrombosis, heart failure, ventricular fibrillation, and death was 10.71% in group A, 25.00% in group B, and 53.75% in group C. There was statistical significance in the onset of cardiovascular adverse effects 3 months postoperation among all three groups (P < 0.05).

Conclusion

Dapagliflozin with metoprolol sustained-release tablets can be effective in improving the heart function, inflammatory response, oxidative stress response, and prognosis in patients after PCI.

Prognosis and Medical Cost of Measuring Fractional Flow Reserve in Percutaneous Coronary Intervention

Background

There are limited data regarding comparative prognosis and medical cost between fractional flow reserve (FFR)-based and angiography-based percutaneous coronary intervention (PCI) among revascularized patients.

Objectives

This study evaluates prognosis and medical cost of FFR use in revascularized patients by PCI.

Methods

Using the National Health Insurance Service database, stable or unstable angina patients who underwent PCI from 2011 to 2017 were evaluated. Eligible patients were divided into 2 groups according to use of FFR in PCI. Primary outcome was a composite of all-cause death or spontaneous myocardial infarction (MI). Secondary outcomes included individual components of the primary outcome, unplanned revascularization, and medical costs.

Results

Among 134,613 eligible patients, PCI was performed based on angiography (n = 129,497) and FFR (n = 5,116). During the study period, both the annual number and proportion of use of FFR in PCI increased (all P for trend <0.001). The FFR group showed significantly lower risk of the primary outcome (7.0% vs 9.5%; P < 0.001), all-cause death (5.8% vs 7.7%; P = 0.001), and spontaneous MI (1.6% vs 2.2%; P = 0.022) than the angiography group. Although the FFR group showed higher medical cost during index admission than angiography group (median: $6,265.10 vs $5,385.60; P < 0.001), cumulative medical cost after index admission was significantly lower ($2,696.50 vs. $3,142.10; P < 0.001).

Conclusions

Use of FFR in PCI in stable or unstable angina patients showed significantly lower risk of all-cause death and spontaneous MI compared to angiography-based PCI. Although the FFR group had higher initial medical cost than the angiography group, cumulative medical cost after index admission was significantly lower.

Benefit and risk of prolonged dual antiplatelet therapy after drug-eluting stent implantation in patients with chronic kidney disease: A nationwide cohort study

BACKGROUND AND AIMS

The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stent in patients with chronic kidney disease (CKD) is not clearly established. This study purposed to compare clinical outcomes of patients with 6-12 (standard) versus 12-24 months (prolonged) DAPT according to CKD.

METHODS

Using a nationwide, claim-based database, we retrospectively evaluated association between DAPT duration and clinical outcomes including death, composite ischemic event, and composite bleeding event between 1 and 3 years after PCI. CKD was defined as estimated glomerular filtration rate <60 mL/min/1.73 m². Of 73,941 eligible patients, 13,425 (18.2%) had CKD and 49,019 (66%) were prescribed prolonged DAPT. Prolonged DAPT had no significant impact on the risk of clinical outcomes in patients with normal renal function.

RESULTS

In patients with CKD, prolonged DAPT was associated with a lower risk of all-cause death (HR 0.85, 95% CI 0.76-0.95) and composite ischemic events (HR 0.87, 95% CI 0.78-0.96) and a higher risk of composite bleeding events (HR 1.18, 95% CI 1.02-1.37). Benefit of prolonged DAPT on reducing composite ischemic event increased significantly in patients with worsened renal dysfunction (p_interaction = 0.02) while there was no significant interaction between its bleeding risk and renal dysfunction (p_interaction = 0.22).

CONCLUSIONS

While standard DAPT would be recommended in patients with normal renal function, tailored decision for DAPT duration would be considered in those with CKD to balance between ischemic and bleeding risks.

Long-Term Beta-Blocker Therapy in Patients With Stable Coronary Artery Disease After Percutaneous Coronary Intervention

Background

It is unclear whether beta-blocker treatment is advantageous in patients with stable coronary artery disease (CAD) who underwent percutaneous coronary intervention (PCI). We evaluated the clinical impact of long-term beta-blocker maintenance in patients with stable CAD after PCI with drug-eluting stent (DES).

Methods

From a nationwide cohort database, we identified the stable CAD patients without current or prior history of myocardial infarction or heart failure who underwent DES implantation. An intention-to-treat principle was used to analyze the impact of beta-blocker treatment on long-term outcomes of major adverse cardiovascular events (MACE) composed of cardiovascular death, myocardial infarction, and hospitalization with heart failure.

Results

After stabilized inverse probability of treatment weighting, a total of 78,380 patients with stable CAD was enrolled; 45,746 patients with and 32,634 without beta-blocker treatment. At 5 years after PCI with a 6-month quarantine period, the adjusted incidence of MACE was significantly higher in patients treated with beta-blockers [10.0 vs. 9.1%; hazard ratio (HR) 1.11, 95% CI 1.06–1.16, p &lt; 0.001] in an intention-to-treat analysis. There was no significant difference in all-cause death between patients treated with and without beta-blockers (8.1 vs. 8.2%; HR 0.99, 95% CI 0.94–1.04, p = 0.62). Statistical analysis with a time-varying Cox regression and rank-preserving structure failure time model revealed similar results to the intention-to-treat analysis.

Conclusions

Among patients with stable CAD undergoing DES implantation, long-term maintenance with beta-blocker treatment might not be associated with clinical outcome improvement.

Trial Registration

ClinicalTrial.gov (NCT04715594).

Long-Term Beta-Blocker Therapy After Myocardial Infarction Without Heart Failure in the Reperfusion Era-Systemic Review and Meta-analysis

ABSTRACT

Beta-blockers are recommended as a standard treatment for patients who experience a myocardial infarction (MI). However, the evidence supporting this recommendation is based on the prereperfusion era data. This review aims to evaluate the effectiveness of long-term (≥1 year) beta-blocker therapy in post-MI patients without clinical heart failure (HF) in the reperfusion era. We included observational cohort studies, which compared at least 1 year use of beta-blockers to no beta-blockers in patients with an acute MI, but without HF. The clinical endpoint considered was all-cause mortality, except for cardiovascular death in one study. Five cohort studies and 217,532 patients were included. One study demonstrated a reduction in all-cause mortality with beta-blockers, whereas, in 4 studies, there was no difference in the death rate. The pooled estimate by random effect showed that beta-blocker treatment does not reduce mortality (odds ratio 0.800, 95% confidence interval 0.559-1.145) with high heterogeneity (I2 = 94%). This meta-analysis shows that the use of oral beta-blockers for 1 year or more does not reduce the mortality of MI patients without HF. Large randomized trials need to evaluate beta-blocker discontinuation after an acute MI.

Long-Term Clinical Outcomes Between Biodegradable and Durable Polymer Drug-Eluting Stents: A Nationwide Cohort Study

Background

Despite the theoretical benefits of biodegradable polymer drug-eluting stents (BP-DES), clinical benefits of BP-DES over durable polymer DES (DP-DES) have not been clearly demonstrated. Using data from a large-volume nationwide cohort, we compared long-term clinical outcomes between BP-DES- and DP-DES-treated patients.

Methods

A retrospective cohort study that enrolled all patients who underwent percutaneous coronary intervention (PCI) with new-generation DES between 2010 and 2016 in Korea was conducted by using the National Health Insurance Service database. The outcomes of interest were all-cause death, cardiovascular death, and myocardial infarction (MI).

Results

A total of 127,731 patients treated with new-generation DES with thin struts (<90 μm) were enrolled for this analysis. After stabilized inverse probability of treatment weighting, the incidence of all-cause death was significantly lower in patients treated with BP-DES (n = 19,521) at 5 years after PCI (11.3 vs. 13.0% in those treated with DP-DES [n = 108,067], hazard ratio [HR] 0.92, 95% confidence interval [CI], 0.88–0.96, p < 0.001), while showing no statistically significant difference at 2 years after PCI (5.7 vs. 6.0%, respectively, HR 0.95, 95% CI, 0.89–1.01, p = 0.238). Similarly, use of BP-DES was associated with a lower incidence of cardiovascular death (7.4 vs. 9.6% in those treated with DP-DES, HR 0.82, 95% CI, 0.77–0.87, p < 0.001), and MI (7.4 vs. 8.7%, respectively, HR 0.90, 95% CI, 0.86–0.94, p = 0.006) at 5 years after PCI. There was no statistically significant difference of cardiovascular death (4.6 vs. 4.9%, respectively, HR 0.93, 95% CI, 0.85–1.01, p = 0.120) and MI (5.0 vs. 5.1%, respectively, HR 0.98, 95% CI, 0.92–1.05, p = 0.461) at 2 years after PCI.

Conclusions

Implantation of BP-DES was associated with a lower risk of all-cause death, cardiovascular death, and MI compared with DP-DES implantation. This difference was clearly apparent at 5 years after DES implantation.

Clinical Trial Registration

ClinicalTrial.gov, NCT04715594.

Qishen Granule (QSG) Inhibits Monocytes Released From the Spleen and Protect Myocardial Function via the TLR4-MyD88-NF-κB p65 Pathway in Heart Failure Mice

Preliminary clinical and basic researches have proved that Qishen granule (QSG) is an effective prescription for treating heart failure (HF) in China, with a characteristic of regulating the ratio of M1/M2 macrophage in the myocardium. However, the regulative mechanism of monocytes targeting the cardio-splenic axis has not been fully elucidated. This study aimed to investigate the effects and mechanism of QSG inhibiting the release of splenic monocytes and the recruitment of myocardial tissue both in vivo and in vitro. Experiments in mice with acute myocardial infarction (AMI)-induced HF demonstrated that QSG could exert anti-inflammatory effects by inhibiting splenic monocytes release and phenotypic changes. Moreover, in vitro experiments indicated QSG could inhibit LPS-stimulated macrophage-conditioned medium (CM)-induced H9C2 cardiomyocyte injury by upregulating the key proteins in TLR4-MyD88-NF-κB p65 pathway. In addition, knockdown or overexpression of TLR4 in H9C2 cells further confirmed that QSG could attenuate inflammatory injury in cardiomyocytes via the TLR4-MyD88-NF-κB p65 pathway. Overall, these data suggested that QSG could improve cardiac function and reduce the inflammatory response in AMI-induced HF by inhibiting splenic monocytes release, and protecting myocardial function via the TLR4-MyD88-NF-κB pathway in heart failure mice.

The duration of beta-blocker therapy and outcomes in patients without heart failure or left ventricular systolic dysfunction after acute myocardial infarction: A multicenter prospective cohort study

Background

The duration of beta‐blocker therapy in patients without heart failure (HF) or left ventricular systolic dysfunction after acute myocardial infarction (AMI) is unclear.

Hypothesis

Continuous beta‐blocker therapy is associated with an improved prognosis.

Methods

This is a prospective, multicenter, cohort study. One thousand four hundred and eighty‐three patients eventually met the inclusion criteria. The study groups included the continuous beta‐blocker therapy group (lasted ≥6 months) and the discontinuous beta‐blocker therapy group (consisting of the no‐beta‐blocker therapy group and the beta‐blocker therapy <6 months group). The inverse probability treatment weighting was used to control confounding factors. The study tried to learn the role of continuous beta‐blocker therapy on outcomes. The median duration of follow‐up was 13.0 months. The primary outcomes were cardiac death and major adverse cardiovascular events (MACE). The secondary outcomes were all‐cause death, stroke, unstable angina, rehospitalization for HF, and recurrent myocardial infarction (MI).

Results

Compared with discontinuous beta‐blocker therapy, continuous beta‐blocker therapy was associated with a reduced risk of unstable angina, recurrent MI, and MACE (hazard ratio [HR]: 0.51; 95% CI: 0.32–0.82; p = 0.006); but this association was not available for cardiac death (HR: 0.57; 95% CI: 0.24–1.36; p = 0.206). When compared to the subgroups of no‐beta‐blocker therapy and beta‐blocker therapy <6 months, respectively, continuous beta‐blocker therapy was still observed to be associated with a reduced risk of unstable angina, recurrent MI, and MACE.

Conclusions

Continuous beta‐blocker therapy was associated with a reduced risk of unstable angina or recurrent MI or MACE in patients without HF or left ventricular systolic dysfunction after AMI.

Effect of long-term beta-blocker treatment following myocardial infarction among stable, optimally treated patients without heart failure in the reperfusion era: a Danish, nationwide cohort study

AIMS

We aimed to investigate the long-term cardio-protective effect associated with beta-blocker (BB) treatment in stable, optimally treated myocardial infarction (MI) patients without heart failure (HF).

METHODS AND RESULTS

Using nationwide registries, we included patients with first-time MI undergoing coronary angiography (CAG) or percutaneous coronary intervention (PCI) during admission and treated with both acetyl-salicylic acid and statins post-discharge between 2003 and 2018. Patients with prior history of MI, prior BB use, or any alternative indication or contraindication for BB treatment were excluded. Follow-up began 3 months following discharge in patients alive, free of cardiovascular (CV) events or procedures. Primary outcomes were CV death, recurrent MI, and a composite outcome of CV events. We used adjusted logistic regression and reported standardized absolute risks and differences (ARD) 3 years after MI. Overall, 30 177 stable, optimally treated MI patients were included (58% acute PCI, 26% sub-acute PCI, 16% CAG without intervention). At baseline, 82% of patients were on BB treatment (median age 61 years, 75% male) and 18% were not (median age 62 years, 68% male). BB treatment was associated with a similar risk of CV death, recurrent MI, and the composite outcome of CV events compared with no BB treatment [ARD (95% confidence intervals)] correspondingly; 0.1% (-0.3% to 0.5%), 0.2% (-0.7% to 1.2%), and 1.2% (-0.2% to 2.7%).

CONCLUSIONS

In this nationwide cohort study of stable, optimally treated MI patients without HF, we found no long-term effect of BB treatment on CV prognosis following the patients from 3 months to 3 years after MI admission.

Learning whether to subtract beta-blockers: it's about time

Proposed framework for foundational and provisional secondary prevention therapy over time in low-risk post-MI patients. Foundational therapies should be considered in all patients without contraindications, while provisional therapies should be considered in selected patients with comorbidities or post-infarction complications. The horizontal time axis proposes duration of therapies and timeframes for pharmacotherapeutic re-assessment, and should be responsive to the temporal evolution of post-MI risk and events. ADP, adenosine diphosphate receptor inhibitors; ASA, acetylsalicylic acid; CKD, chronic kidney disease; DM, diabetes mellitus; HTN, hypertension; RAAS, renin-angiotensin-aldosterone system; RCT, randomized controlled trials; TG, triglyceride. *Pending guideline recommendations.

Prognostic impacts of β-blockers in acute coronary syndrome patients without heart failure treated by percutaneous coronary intervention

BACKGROUND

The use of β-blockers for acute coronary syndrome (ACS) patients without heart failure (HF) is controversial, and lacks of evidence in the era of reperfusion and intensive secondary preventions. This study aimed to investigate the prognostic impacts of β-blockers on patients with ACS but no HF treated by percutaneous coronary intervention (PCI).

METHODS

A total of 2397 consecutive patients with ACS but no HF treated by PCI were retrospectively recruited from January 2010 to June 2017. Univariable Cox regression was used to assess the prognostic impacts of β-blockers, followed by adjusted analysis, one-to-one propensity score matching (PSM), and inverse probability treatment weighting (IPTW) analysis, in order to control for systemic between-group differences. The primary outcome was all-cause death.

RESULTS

Among the included patients, 2060 (85.9%) were prescribed with β-blockers at discharge. The median follow-up time was 727 (433-2016) days, with 55 (2.3%) cases of all-cause death. Unadjusted analysis showed that the use of β-blockers was associated with lower risk of death (hazard ratio [HR]: 0.42, 95% confidence interval [CI]: 0.23-0.76, P = 0.004), which was sustained in adjusted analysis (HR: 0.53, 95% CI: 0.29-0.98, P = 0.044), PSM analysis (HR: 0.44, 95% CI: 0.20-0.96, P = 0.039) and IPTW analysis (HR: 0.49. 95% CI: 0.35-0.70, P < 0.001). Risk reduction was also seen in β-blocker users for cardiac death, but not for major adverse cardiovascular events.

CONCLUSIONS

The use of β-blockers was associated with reduced long-term mortality for ACS-PCI patients without HF.

Pharmacotherapy for acute myocardial infarction

Clinical practice guidelines published by the European Society of Cardiology and the American College of Cardiology/ American Heart Association provide recommendations based on evidence, including randomized controlled trials and registry data, for clinicians to enable efficient clinical decision-making and improve prognosis for patients with acute myocardial infarction (AMI). However, there are several differences in practice, health systems, and races between Korea and Western countries; further, many studies on pharmacotherapy were conducted in the prepercutaneous coronary intervention era. An expert consensus document on pharmacotherapy for AMI was recently published following demands for the establishment of Korean guideline reflecting data in the modern percutaneous coronary intervention era. In this review, we summarized AMI guidelines from Europe, America, Japan, and Korea, and analyzed studies on pharmacotherapy for AMI including well-organized randomized controlled trials by Korean researchers and large-sized registry datasets, such as the Korea Acute Myocardial Infarction Registry and the Korean National Health Insurance Service.

Inter-vendor comparison of left atrial strain using layer specific strain analysis

Left atrial strain (LAS) on transthoracic echocardiogram (TTE) is increasingly recognised to have clinical utility in cardiovascular disease. Differences in LAS measurements between vendors remains a barrier for clinical use. We sought to compare LAS between two commonly used software platforms; the layer-specific endocardial and mid-myocardial measurements of LAS on General Electric (GE) Echopac were compared to TomTec strain. LAS was measured in 88 individuals with no previous cardiac history and 40 paroxysmal AF (PAF) patients, in sinus rhythm at TTE. Conventionally, LAS measured using GE Echopac is mid-myocardial strain (GE-mid); additionally, endocardial (GE-endo) LAS was evaluated. Both LAS measurements by GE were compared to TomTec-Arena (v2.30.02) measurements. Reservoir (ƐR), contractile (ƐCT) and conduit (ƐCD) phasic strain were evaluated. Both GE-mid and GE-endo LAS correlated well with TomTec LAS. On Bland-Altman analysis, GE-mid LAS measurements were systematically lower than TomTec LAS (ƐR: mean difference (MD) - 6.08%, limits of agreement (LOA) - 12%, 0%, ƐCT: MD - 0.8%, LOA - 7%, 5%, ƐCD: MD - 5.2% LOA - 12%, 1%). GE-endo LAS demonstrated no systematic difference from TomTec LAS, but had wider limits of agreement (ƐR: MD 0.41%, LOA - 7%, 8%, ƐCT: MD 0.50%, LOA - 6%, 7%, ƐCD: MD - 0.08%, LOA - 7%, 7%). ƐR had the best reproducibility. Mid-myocardial LAS, routinely evaluated by GE Echopac software, systematically underestimates LAS compared to TomTec. Using GE endocardial LAS eliminated this bias, but introduced greater variation between measurements. Serial measurements of LAS should therefore be performed on the same vendor system.