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? blockers and mortality after myocardial infarction in patients without heart failure: multicentre prospective cohort study.

ABSTRACT: OBJECTIVE:To assess the association between early and prolonged ? blocker treatment and mortality after acute myocardial infarction. DESIGN:Multicentre prospective cohort study. SETTING:Nationwide French registry of Acute ST- and non-ST-elevation Myocardial Infarction (FAST-MI) (at 223 centres) at the end of 2005. PARTICIPANTS:2679 consecutive patients with acute myocardial infarction and without heart failure or left ventricular dysfunction. MAIN OUTCOME MEASURES:Mortality was assessed at 30 days in relation to early use of ? blockers (?48 hours of admission), at one year in relation to discharge prescription, and at five years in relation to one year use. RESULTS:? blockers were used early in 77% (2050/2679) of patients, were prescribed at discharge in 80% (1783/2217), and were still being used in 89% (1230/1383) of those alive at one year. Thirty day mortality was lower in patients taking early ? blockers (adjusted hazard ratio 0.46, 95% confidence interval 0.26 to 0.82), whereas the hazard ratio for one year mortality associated with ? blockers at discharge was 0.77 (0.46 to 1.30). Persistence of ? blockers at one year was not associated with lower five year mortality (hazard ratio 1.19, 0.65 to 2.18). In contrast, five year mortality was lower in patients continuing statins at one year (hazard ratio 0.42, 0.25 to 0.72) compared with those discontinuing statins. Propensity score and sensitivity analyses showed consistent results. CONCLUSIONS:Early ? blocker use was associated with reduced 30 day mortality in patients with acute myocardial infarction, and discontinuation of ? blockers at one year was not associated with higher five year mortality. These findings question the utility of prolonged ? blocker treatment after acute myocardial infarction in patients without heart failure or left ventricular dysfunction.Trial registration Clinical trials NCT00673036.

SUBMITTER: Puymirat E

PROVIDER: S-EPMC5029148 | biostudies-literature | 2016 Sep

REPOSITORIES: biostudies-literature

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β blockers and mortality after myocardial infarction in patients without heart failure: multicentre prospective cohort study.

Puymirat Etienne E Riant Elisabeth E Aissaoui Nadia N Soria Angèle A Ducrocq Gregory G Coste Pierre P Cottin Yves Y Aupetit Jean François JF Bonnefoy Eric E Blanchard Didier D Cattan Simon S Steg Gabriel G Schiele François F Ferrières Jean J Juillière Yves Y Simon Tabassome T Danchin Nicolas N

BMJ (Clinical research ed.) 20160920

<h4>Objective</h4>To assess the association between early and prolonged β blocker treatment and mortality after acute myocardial infarction.<h4>Design</h4>Multicentre prospective cohort study.<h4>Setting</h4>Nationwide French registry of Acute ST- and non-ST-elevation Myocardial Infarction (FAST-MI) (at 223 centres) at the end of 2005.<h4>Participants</h4>2679 consecutive patients with acute myocardial infarction and without heart failure or left ventricular dysfunction.<h4>Main outcome measures ...[more]

PMID: 27650822

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Project description:BackgroundFor acute myocardial infarction (AMI) without heart failure (HF), it is unclear if β-blockers are associated with reduced mortality.ObjectivesThe goal of this study was to determine the association between β-blocker use and mortality in patients with AMI without HF or left ventricular systolic dysfunction (LVSD).MethodsThis cohort study used national English and Welsh registry data from the Myocardial Ischaemia National Audit Project. A total of 179,810 survivors of hospitalization with AMI without HF or LVSD, between January 1, 2007, and June 30, 2013 (final follow-up: December 31, 2013), were assessed. Survival-time inverse probability weighting propensity scores and instrumental variable analyses were used to investigate the association between the use of β-blockers and 1-year mortality.ResultsOf 91,895 patients with ST-segment elevation myocardial infarction and 87,915 patients with non-ST-segment elevation myocardial infarction, 88,542 (96.4%) and 81,933 (93.2%) received β-blockers, respectively. For the entire cohort, with >163,772 person-years of observation, there were 9,373 deaths (5.2%). Unadjusted 1-year mortality was lower for patients who received β-blockers compared with those who did not (4.9% vs. 11.2%; p < 0.001). However, after weighting and adjustment, there was no significant difference in mortality between those with and without β-blocker use (average treatment effect [ATE] coefficient: 0.07; 95% confidence interval [CI]: -0.60 to 0.75; p = 0.827). Findings were similar for ST-segment elevation myocardial infarction (ATE coefficient: 0.30; 95% CI: -0.98 to 1.58; p = 0.637) and non-ST-segment elevation myocardial infarction (ATE coefficient: -0.07; 95% CI: -0.68 to 0.54; p = 0.819).ConclusionsAmong survivors of hospitalization with AMI who did not have HF or LVSD as recorded in the hospital, the use of β-blockers was not associated with a lower risk of death at any time point up to 1 year. (β-Blocker Use and Mortality in Hospital Survivors of Acute Myocardial Infarction Without Heart Failure; NCT02786654).

Project description:AimsThe aim of this study is to investigate the association between adherence to beta-blocker treatment after a first acute myocardial infarction (AMI) and long-term risk of heart failure (HF) and death.Methods and resultsAll patients admitted for a first AMI included in the nationwide Swedish web-system for enhancement and development of evidence-based care in heart disease evaluated according to recommended therapies register between 2005 and 2010 were eligible (n = 71 638). After exclusion of patients who died in-hospital, patients with previous HF, patients with unknown left ventricular ejection fraction (EF), and patients who died during the first year after the index event, 38 608 patients remained in the final analysis. Adherence to prescribed beta-blockers was determined for 1 year after the index event using the national registry for prescribed drugs and was measured as proportion of days covered, the ratio between the numbers of days covered by the dispensed prescriptions and number of days in the period. As customary, a threshold level for proportion of days covered ≥80% was used to classify patients as adherent or non-adherent. At discharge 90.6% (n = 36 869) of all patients were prescribed a beta-blocker. Among 38 608 1 year survivors, 31.1% (n = 12 013) were non-adherent to beta-blockers. Patients with reduced EF with and without HF were more likely to remain adherent to beta-blockers at 1-year compared with patients with normal EF without HF (NEF). Being married/cohabiting and having higher income level, hypertension, ST-elevation MI, and percutaneous coronary intervention were associated with better adherence. Adherence was independently associated with lower all-cause mortality [hazard ratio (HR) 0.77, 95% confidence interval [CI] 0.71-0.84] and a lower risk for the composite of HF readmission/death, (HR 0.83, 95% CI 0.78-0.89, P value <0.001) during the subsequent 4 years of follow up. These associations were favourable but less apparent in patients with HFNEF and NEF.ConclusionsNearly one in three AMI patients was non-adherent to beta-blockers within the first year. Adherence was independently associated with improved long-term outcomes; however, uncertainty remains for patients with HFNEF and NEF.

Project description:BackgroundThe role of beta-blockers in acute myocardial infarction patients without heart failure and with preserved left ventricular ejection fraction (LVEF ≥ 50%) is unknown. Our study aimed to retrospectively analyze the associations of beta-blockers on such patients.MethodsThis is a multicenter, retrospective study. After screening 5,332 acute myocardial infarction patients, a total of 2519 patients without heart failure and with LVEF ≥ 50% were included. The patients were divided into two groups: the prescribed (n = 2049) and unprescribed (n = 470) beta-blockers group. The propensity score inverse probability treatment weighting was used to control confounding factors. We analyzed the associations between beta-blockers and outcomes in the short-term (1-year) and long-term (median, 3.61 years).ResultsThe primary outcome was all-cause mortality. The secondary outcomes were all-cause rehospitalization, cardiac death, recurrent myocardial infarction, new-onset heart failure rehospitalization. This study shows no statistically significant association between discharged with beta-blockers and all-cause mortality, either in the short-term [IPTW Adjusted, HR 1.02; 95%CI 0.43-2.40; P = 0.966] or long-term [IPTW Adjusted, HR 1.17; 95%CI 0.70-1.94; P = 0.547]. Discharged with beta-blockers was significantly associated with a reduced risk of short-term recurrent myocardial infarction [IPTW Adjusted, HR 0.44; 95%CI 0.20-0.97; P = 0.043], but there was no long-term relationship [IPTW Adjusted, HR 1.11; 95%CI 0.61-2.03; P = 0.735]. Other outcomes, such as new-onset heart failure rehospitalization and all-cause rehospitalization, were not observed with meaningful differences in either the short- or long-term. The results of sensitivity analysis were consistent with this.ConclusionsBeta-blockers might be associated with a reduced risk of recurrent myocardial infarction in patients without heart failure and with preserved left ventricular ejection fraction after acute myocardial infarction, in the short term. Beta-blockers might not be related to all-cause mortality in those patients, either in the short-term or long-term. Clinical trial registration Influence of Beta-blockers on Prognosis in Patients with Acute Myocardial Infarction Complicated with Normal Ejection Fraction, NCT04485988, Registered on 24/07/2020. Retrospectively registered.

Project description:Importance:Hospitals in the United States have been subject to mandatory public reporting of mortality rates for acute myocardial infarction (AMI) and heart failure (HF) since 2007 and to value-based payment programs for these conditions since 2011. However, whether hospitals with initially poor baseline performance have improved relative to other hospitals under these programs, and whether patterns of improvement differ by condition, is unknown. Understanding trends within public reporting and value-based payment can inform future efforts in these areas. Objective:To examine patterns in 30-day mortality from AMI and HF and determine whether they differ for baseline poor performers (worst quartile in 2009 and 2010 in public reporting, prior to value-based payment) compared with other hospitals. Design, Setting, and Participants:Retrospective cross-sectional study at US acute care hospitals from 2009 to 2015 that included 2751 and 3796 hospitals with publicly reported mortality data for AMI and HF, respectively. Exposures:Public reporting and value-based purchasing. Main Outcomes and Measures:Hospital-level risk-adjusted 30-day mortality rates. Results:We identified 422 and 600 baseline poor-performing hospitals for AMI and HF, respectively. Baseline poor performers for AMI were more often public and for-profit and less often teaching hospitals. Baseline poor performers for HF were less often large hospitals. For AMI, 30-day mortality among baseline poor performers was higher at baseline but improved more over time compared with other hospitals (18.6% in 2009 to 14.6% in 2015; -0.74% per year; P?<?.001 vs 15.7% in 2009 to 14.0% in 2015; -0.26% per year; P?<?.001; P for interaction <.001). In contrast, for HF, baseline poor performers improved over time (13.5%-13.0%; -0.12% per year; P?<?.001), but mean mortality among all other HF hospitals increased during the study period (10.9%-12.0%; 0.17% per year; P?<?.001; P for interaction, <.001). Conclusions and Relevance:Despite being subject to identical policy pressures, mortality trends for AMI and HF differed markedly between 2009 and 2015.

Project description:Importance:Treatment with aldosterone antagonists is recommended and has been shown to have beneficial effects in patients with ST-segment elevation myocardial infarction (STEMI) and left ventricular ejection fraction (LVEF) less than 40%. However, the role of aldosterone antagonists in patients with ejection fraction greater than 40% or without congestive heart failure is not well known. Objectives:To perform a systematic review and meta-analysis using standard techniques to determine the role of therapy with aldosterone antagonists in this patient population. Data Sources:PubMed, Embase, CINAHL, and Cochrane Central databases were searched and a manual search for relevant references from the selected articles and published reviews was performed from database inception through June 2017. Study Selection:Randomized clinical trials that evaluated treatment with aldosterone antagonists in patients with STEMI without clinical heart failure or LVEF greater than 40% were included. Data Extraction and Synthesis:Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used to conduct and report the meta-analysis, which used a random-effects model. Two investigators independently performed the database search and agreed on the final study selection. A manual search was performed for relevant references from the selected articles and published reviews. Main Outcomes and Measures:The outcomes analyzed were mortality, new congestive heart failure, recurrent myocardial infarction, ventricular arrhythmia, and changes in LVEF, serum potassium level, and creatinine level at follow-up. Results:In all, 10 randomized clinical trials with a total of 4147 unique patients were included in the meta-analysis. In patients who presented with STEMI without heart failure, treatment with aldosterone antagonists compared with control was associated with lower risk of mortality (2.4% vs 3.9%; odds ratio [OR], 0.62; 95% CI, 0.42-0.91; P = .01) and similar risks of myocardial infarction (1.6% vs 1.5%; OR, 1.03; 95% CI, 0.57-1.86; P = .91), new congestive heart failure (4.3% vs 5.4%; OR, 0.82; 95% CI, 0.56-1.20; P = .31), and ventricular arrhythmia (4.1% vs 5.1%; OR, 0.76; 95% CI, 0.45-1.31; P = .33). Similarly, treatment with aldosterone antagonists compared with control was associated with a small yet significant increase in LVEF (mean difference, 1.58%; 95% CI, 0.18%-2.97%; P = .03), a small increase in serum potassium level (mean difference, 0.07 mEq/L; 95% CI, 0.01-0.13 mEq/L; P = .02), and no change in serum creatinine level (standardized mean difference, 1.4; 95% CI, -0.43 to 3.24; P = .13). Conclusions and Relevance:Treatment with aldosterone antagonists is associated with a mortality benefit in patients with STEMI with LVEF greater than 40% or without heart failure.

Dataset Information

? blockers and mortality after myocardial infarction in patients without heart failure: multicentre prospective cohort study.

Publications

β blockers and mortality after myocardial infarction in patients without heart failure: multicentre prospective cohort study.

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