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

Debate exists about the efficacy of β-blockers in myocardial infarction and their required duration of usage in contemporary practice. We conducted a MEDLINE/EMBASE/CENTRAL search for randomized trials evaluating β-blockers in myocardial infarction enrolling at least 100 patients. The primary outcom...

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Vydáno v:	The American journal of medicine Ročník 127; číslo 10; s. 939
Hlavní autoři:	Bangalore, Sripal, Makani, Harikrishna, Radford, Martha, Thakur, Kamia, Toklu, Bora, Katz, Stuart D, DiNicolantonio, James J, Devereaux, P J, Alexander, Karen P, Wetterslev, Jorn, Messerli, Franz H
Médium:	Journal Article
Jazyk:	angličtina
Vydáno:	United States 01.10.2014
Témata:	Adrenergic beta-Antagonists - administration & dosage Adrenergic beta-Antagonists - adverse effects Adrenergic beta-Antagonists - therapeutic use Cause of Death Comorbidity Databases, Bibliographic Heart Failure - epidemiology Humans Myocardial Infarction - drug therapy Myocardial Infarction - mortality Myocardial Infarction - therapy Myocardial Reperfusion - statistics & numerical data Randomized Controlled Trials as Topic Shock, Cardiogenic - epidemiology Time Factors Treatment Outcome Myocardial infarction β-blockers Reperfusion Outcomes
ISSN:	1555-7162, 1555-7162
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Abstract	Debate exists about the efficacy of β-blockers in myocardial infarction and their required duration of usage in contemporary practice. We conducted a MEDLINE/EMBASE/CENTRAL search for randomized trials evaluating β-blockers in myocardial infarction enrolling at least 100 patients. The primary outcome was all-cause mortality. Analysis was performed stratifying trials into reperfusion-era (> 50% undergoing reperfusion or receiving aspirin/statin) or pre-reperfusion-era trials. Sixty trials with 102,003 patients satisfied the inclusion criteria. In the acute myocardial infarction trials, a significant interaction (Pinteraction = .02) was noted such that β-blockers reduced mortality in the pre-reperfusion (incident rate ratio [IRR] 0.86; 95% confidence interval [CI], 0.79-0.94) but not in the reperfusion era (IRR 0.98; 95% CI, 0.92-1.05). In the pre-reperfusion era, β-blockers reduced cardiovascular mortality (IRR 0.87; 95% CI, 0.78-0.98), myocardial infarction (IRR 0.78; 95% CI, 0.62-0.97), and angina (IRR 0.88; 95% CI, 0.82-0.95), with no difference for other outcomes. In the reperfusion era, β-blockers reduced myocardial infarction (IRR 0.72; 95% CI, 0.62-0.83) (number needed to treat to benefit [NNTB] = 209) and angina (IRR 0.80; 95% CI, 0.65-0.98) (NNTB = 26) at the expense of increase in heart failure (IRR 1.10; 95% CI, 1.05-1.16) (number needed to treat to harm [NNTH] = 79), cardiogenic shock (IRR 1.29; 95% CI, 1.18-1.41) (NNTH = 90), and drug discontinuation (IRR 1.64; 95% CI, 1.55-1.73), with no benefit for other outcomes. Benefits for recurrent myocardial infarction and angina in the reperfusion era appeared to be short term (30 days). In contemporary practice of treatment of myocardial infarction, β-blockers have no mortality benefit but reduce recurrent myocardial infarction and angina (short-term) at the expense of increase in heart failure, cardiogenic shock, and drug discontinuation. The guideline authors should reconsider the strength of recommendations for β-blockers post myocardial infarction.
AbstractList	Debate exists about the efficacy of β-blockers in myocardial infarction and their required duration of usage in contemporary practice.BACKGROUNDDebate exists about the efficacy of β-blockers in myocardial infarction and their required duration of usage in contemporary practice.We conducted a MEDLINE/EMBASE/CENTRAL search for randomized trials evaluating β-blockers in myocardial infarction enrolling at least 100 patients. The primary outcome was all-cause mortality. Analysis was performed stratifying trials into reperfusion-era (> 50% undergoing reperfusion or receiving aspirin/statin) or pre-reperfusion-era trials.METHODSWe conducted a MEDLINE/EMBASE/CENTRAL search for randomized trials evaluating β-blockers in myocardial infarction enrolling at least 100 patients. The primary outcome was all-cause mortality. Analysis was performed stratifying trials into reperfusion-era (> 50% undergoing reperfusion or receiving aspirin/statin) or pre-reperfusion-era trials.Sixty trials with 102,003 patients satisfied the inclusion criteria. In the acute myocardial infarction trials, a significant interaction (Pinteraction = .02) was noted such that β-blockers reduced mortality in the pre-reperfusion (incident rate ratio [IRR] 0.86; 95% confidence interval [CI], 0.79-0.94) but not in the reperfusion era (IRR 0.98; 95% CI, 0.92-1.05). In the pre-reperfusion era, β-blockers reduced cardiovascular mortality (IRR 0.87; 95% CI, 0.78-0.98), myocardial infarction (IRR 0.78; 95% CI, 0.62-0.97), and angina (IRR 0.88; 95% CI, 0.82-0.95), with no difference for other outcomes. In the reperfusion era, β-blockers reduced myocardial infarction (IRR 0.72; 95% CI, 0.62-0.83) (number needed to treat to benefit [NNTB] = 209) and angina (IRR 0.80; 95% CI, 0.65-0.98) (NNTB = 26) at the expense of increase in heart failure (IRR 1.10; 95% CI, 1.05-1.16) (number needed to treat to harm [NNTH] = 79), cardiogenic shock (IRR 1.29; 95% CI, 1.18-1.41) (NNTH = 90), and drug discontinuation (IRR 1.64; 95% CI, 1.55-1.73), with no benefit for other outcomes. Benefits for recurrent myocardial infarction and angina in the reperfusion era appeared to be short term (30 days).RESULTSSixty trials with 102,003 patients satisfied the inclusion criteria. In the acute myocardial infarction trials, a significant interaction (Pinteraction = .02) was noted such that β-blockers reduced mortality in the pre-reperfusion (incident rate ratio [IRR] 0.86; 95% confidence interval [CI], 0.79-0.94) but not in the reperfusion era (IRR 0.98; 95% CI, 0.92-1.05). In the pre-reperfusion era, β-blockers reduced cardiovascular mortality (IRR 0.87; 95% CI, 0.78-0.98), myocardial infarction (IRR 0.78; 95% CI, 0.62-0.97), and angina (IRR 0.88; 95% CI, 0.82-0.95), with no difference for other outcomes. In the reperfusion era, β-blockers reduced myocardial infarction (IRR 0.72; 95% CI, 0.62-0.83) (number needed to treat to benefit [NNTB] = 209) and angina (IRR 0.80; 95% CI, 0.65-0.98) (NNTB = 26) at the expense of increase in heart failure (IRR 1.10; 95% CI, 1.05-1.16) (number needed to treat to harm [NNTH] = 79), cardiogenic shock (IRR 1.29; 95% CI, 1.18-1.41) (NNTH = 90), and drug discontinuation (IRR 1.64; 95% CI, 1.55-1.73), with no benefit for other outcomes. Benefits for recurrent myocardial infarction and angina in the reperfusion era appeared to be short term (30 days).In contemporary practice of treatment of myocardial infarction, β-blockers have no mortality benefit but reduce recurrent myocardial infarction and angina (short-term) at the expense of increase in heart failure, cardiogenic shock, and drug discontinuation. The guideline authors should reconsider the strength of recommendations for β-blockers post myocardial infarction.CONCLUSIONSIn contemporary practice of treatment of myocardial infarction, β-blockers have no mortality benefit but reduce recurrent myocardial infarction and angina (short-term) at the expense of increase in heart failure, cardiogenic shock, and drug discontinuation. The guideline authors should reconsider the strength of recommendations for β-blockers post myocardial infarction. Debate exists about the efficacy of β-blockers in myocardial infarction and their required duration of usage in contemporary practice. We conducted a MEDLINE/EMBASE/CENTRAL search for randomized trials evaluating β-blockers in myocardial infarction enrolling at least 100 patients. The primary outcome was all-cause mortality. Analysis was performed stratifying trials into reperfusion-era (> 50% undergoing reperfusion or receiving aspirin/statin) or pre-reperfusion-era trials. Sixty trials with 102,003 patients satisfied the inclusion criteria. In the acute myocardial infarction trials, a significant interaction (Pinteraction = .02) was noted such that β-blockers reduced mortality in the pre-reperfusion (incident rate ratio [IRR] 0.86; 95% confidence interval [CI], 0.79-0.94) but not in the reperfusion era (IRR 0.98; 95% CI, 0.92-1.05). In the pre-reperfusion era, β-blockers reduced cardiovascular mortality (IRR 0.87; 95% CI, 0.78-0.98), myocardial infarction (IRR 0.78; 95% CI, 0.62-0.97), and angina (IRR 0.88; 95% CI, 0.82-0.95), with no difference for other outcomes. In the reperfusion era, β-blockers reduced myocardial infarction (IRR 0.72; 95% CI, 0.62-0.83) (number needed to treat to benefit [NNTB] = 209) and angina (IRR 0.80; 95% CI, 0.65-0.98) (NNTB = 26) at the expense of increase in heart failure (IRR 1.10; 95% CI, 1.05-1.16) (number needed to treat to harm [NNTH] = 79), cardiogenic shock (IRR 1.29; 95% CI, 1.18-1.41) (NNTH = 90), and drug discontinuation (IRR 1.64; 95% CI, 1.55-1.73), with no benefit for other outcomes. Benefits for recurrent myocardial infarction and angina in the reperfusion era appeared to be short term (30 days). In contemporary practice of treatment of myocardial infarction, β-blockers have no mortality benefit but reduce recurrent myocardial infarction and angina (short-term) at the expense of increase in heart failure, cardiogenic shock, and drug discontinuation. The guideline authors should reconsider the strength of recommendations for β-blockers post myocardial infarction.
Author	Katz, Stuart D Toklu, Bora Alexander, Karen P Wetterslev, Jorn Bangalore, Sripal Thakur, Kamia DiNicolantonio, James J Devereaux, P J Messerli, Franz H Makani, Harikrishna Radford, Martha
Author_xml	– sequence: 1 givenname: Sripal surname: Bangalore fullname: Bangalore, Sripal email: sripalbangalore@gmail.com organization: New York University School of Medicine, New York, NY. Electronic address: sripalbangalore@gmail.com – sequence: 2 givenname: Harikrishna surname: Makani fullname: Makani, Harikrishna organization: St. Luke's Roosevelt Hospital, Mt. Sinai School of Medicine, New York, NY – sequence: 3 givenname: Martha surname: Radford fullname: Radford, Martha organization: New York University School of Medicine, New York, NY – sequence: 4 givenname: Kamia surname: Thakur fullname: Thakur, Kamia organization: New York University School of Medicine, New York, NY – sequence: 5 givenname: Bora surname: Toklu fullname: Toklu, Bora organization: Virginia Commonwealth University, Richmond – sequence: 6 givenname: Stuart D surname: Katz fullname: Katz, Stuart D organization: New York University School of Medicine, New York, NY – sequence: 7 givenname: James J surname: DiNicolantonio fullname: DiNicolantonio, James J organization: Mid America Heart Institute, St. Luke's Hospital, Kansas City, Mo; Wegmans Pharmacy, Ithaca, NY – sequence: 8 givenname: P J surname: Devereaux fullname: Devereaux, P J organization: Population Health Research Institute, Hamilton, Ont., Canada – sequence: 9 givenname: Karen P surname: Alexander fullname: Alexander, Karen P organization: Duke Clinical Research Institute, Durham, NC – sequence: 10 givenname: Jorn surname: Wetterslev fullname: Wetterslev, Jorn organization: The Copenhagen Trial Unit, Copenhagen University Hospital, Copenhagen, Denmark – sequence: 11 givenname: Franz H surname: Messerli fullname: Messerli, Franz H organization: St. Luke's Roosevelt Hospital, Mt. Sinai School of Medicine, New York, NY
BackLink	https://www.ncbi.nlm.nih.gov/pubmed/24927909$$D View this record in MEDLINE/PubMed
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Keywords	Myocardial infarction β-blockers Reperfusion Outcomes
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References	25775346 - Ann Intern Med. 2015 Mar 17;162(6):JC3 25481200 - Am J Med. 2014 Dec;127(12):e17 25481201 - Am J Med. 2014 Dec;127(12):e19
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Snippet	Debate exists about the efficacy of β-blockers in myocardial infarction and their required duration of usage in contemporary practice. We conducted a... Debate exists about the efficacy of β-blockers in myocardial infarction and their required duration of usage in contemporary practice.BACKGROUNDDebate exists...
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SubjectTerms	Adrenergic beta-Antagonists - administration & dosage Adrenergic beta-Antagonists - adverse effects Adrenergic beta-Antagonists - therapeutic use Cause of Death Comorbidity Databases, Bibliographic Heart Failure - epidemiology Humans Myocardial Infarction - drug therapy Myocardial Infarction - mortality Myocardial Infarction - therapy Myocardial Reperfusion - statistics & numerical data Randomized Controlled Trials as Topic Shock, Cardiogenic - epidemiology Time Factors Treatment Outcome
Title	Clinical outcomes with β-blockers for myocardial infarction: a meta-analysis of randomized trials
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