Clinical Outcomes with ?-Blockers for Myocardial Infarction: A Meta-analysis of Randomized Trials - 12/10/14
, Harikrishna Makani, MD b, Martha Radford, MD a, Kamia Thakur, MD a, Bora Toklu, MD c, Stuart D. Katz, MD a, James J. DiNicolantonio, PharmD d, e, P.J. Devereaux, MD, PhD f, Karen P. Alexander, MD g, Jorn Wetterslev, MD, PhD h, Franz H. Messerli, MD bAbstract |
Background |
Debate exists about the efficacy of β-blockers in myocardial infarction and their required duration of usage in contemporary practice.
Methods |
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.
Results |
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).
Conclusions |
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.
Le texte complet de cet article est disponible en PDF.Keywords : β-blockers, Myocardial infarction, Outcomes, Reperfusion
Plan
| Funding: None. |
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| Conflicts of Interest: PJD is part of a group that has a policy of not accepting honorariums or other payments from industry for their own personal financial gain. They do accept honorariums or other payments from industry to support research endeavors and for reimbursement of costs to participate in meetings such as scientific or advisory committee meetings. Based on study questions he originated and grants he wrote, he has received grants from Abbott Diagnostics, Astra Zeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Covidien, Stryker, and Roche Diagnostics. He has also participated in an advisory board meeting for GlaxoSmithKline and an expert panel meeting for Astra Zeneca. The remaining authors have nothing to disclose. |
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| Authorship: All authors had access to the data and played a role in writing this manuscript. |
Vol 127 - N° 10
P. 939-953 - octobre 2014 Retour au numéro
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