Dataset Information

Effectiveness of beta blockers in patients with and without a history of myocardial infarction.

ABSTRACT:

Purpose

Studies demonstrating mortality benefit of beta blockers (BB) after myocardial infarction (MI) were conducted before the era of percutaneous intervention and widespread use of statins. Recent retrospective studies show inconsistent results regarding which subgroups of coronary artery disease (CAD) patients' benefit. Most studies did not account for medication changes over time. We evaluated the association of time-varying BB exposure with death in CAD patients with or without a history of MI.

Methods

This retrospective cohort study included all patients with MI and those with coronary disease but no MI at a single health care system who also had health insurance from January 1, 1997, to June 30, 2011. Pharmacy claims data were used to estimate BB exposure over 6-month rolling windows. The primary endpoint was all-cause death. The effect of BB exposure was tested using time-updated Cox proportional hazards models.

Results

We identified 6220 patients with MI and 21,285 patients with CAD but no MI. Among patients who suffered MI, BB exposure was associated with a 31% relative risk reduction in all-cause death (hazard ratio [HR] 0.69, P = 0.001). Among subjects who survived 3 years after MI, BB retained a protective association (HR 0.71, P = 0.001). Among CAD-only patients, BB exposure was also associated with risk reduction (HR 0.85, P = 0.001).

Conclusion

Among patients with CAD, BB exposure is associated with reduced risk of death. The association is strongest among those who have suffered MI. This favorable association appears durable beyond 3 years.

SUBMITTER: Verma S

PROVIDER: S-EPMC7354894 | biostudies-literature |

REPOSITORIES: biostudies-literature

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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:Abstract Background There is a lack of evidence regarding the benefits of maintenance β–blocker (BB) treatment in post–acute AMI patients (pts) without reduced LVEF in the era of invasive management. Design and Trial Status REBOOT is an independent multinational pragmatic, controlled, randomized, open–label, with blinded endpoint adjudication clinical trial testing the benefits of BB maintenance therapy in post–AMI pts (either with or without ST segment elevation) discharged with LVEF >40%. Patients ≥18 years (yr) old undergoing invasive management during admission and without history of heart failure (HF) are eligible to participate. At discharge, pts are 1:1 randomized to either receive BB (agent and dose chosen by the treating physician) or no BB therapy. The primary endpoint is a composite of “all–cause death, nonfatal reAMI, or HF hospitalization” over a minimum follow–up period of 2 yr. Key secondary endpoints are: a) the incidence rate of each individual component of the composite endpoint; b) cardiovascular death; c) admission for sustained ventricular tachycardia/ventricular fibrillation; and d) admission for atrial fibrillation. Events will be adjudicated by a blinded committee. A sample size of 8468 pts (728 events) was estimated to provide a power of 85% to detect a relative risk reduction of 20% (incidence of primary endpoint in control 10%) and assuming 5% withdrawals. Statistical analyses will be conducted according to the intention–to–treat principle, although a pre–specified per–protocol analysis will also be performed. The Spanish National Center for Cardiovascular Research (CNIC) is the sponsor of the trial, which has no external funding. CNIC coordinates ≥75 Spanish centers, while Istituto di Ricerche Farmacologiche Mario Negri IRCCS coordinate 33 Cardiology Centers distributed in 10 Italian regions. The first pt was included in Spain in October 2018, in Italy in January 2019. The end of enrollment is anticipated in December 2022. At 09 December 2021, 5669 pts had been enrolled from which 1263 in Italy (Figure). Pts baseline characteristics are described in the Table. Hospital admission data for COVID–19 pre and post randomization were also recorded since June 2020. Conclusions The REBOOT trial (NCT03596385) will fill the existing scientific gap on the efficacy of β–BB after AMI in pts with LVEF > 40% and no HF who are treated according to current standard–of–care. REBOOT trial results might have an impact on clinical practice guidelines.

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