Bangalore, Sripal2; Makani, Harikrishna3; Radford, Martha4; Thakur, Kamia5; Toklu, Bora6; Katz, Stuart D7; DiNicolantonio, James J8; Devereaux, P J9; Alexander, Karen P10; Wetterslev, Jorn1; Messerli, Franz H11
1 Copenhagen Trial Unit, Cochranecenteret Rigshospitalet, Rigshospitalet, The Capital Region of Denmark2 New York University School of Medicine, New York, NY. Electronic address: email@example.com St. Luke's Roosevelt Hospital, Mt. Sinai School of Medicine, New York, NY.4 New York University School of Medicine, New York, NY.5 New York University School of Medicine, New York, NY.6 Virginia Commonwealth University, Richmond, VA.7 New York University School of Medicine, New York, NY.8 Mid America Heart Institute, St. Luke's Hospital, Kansas City, Missouri and Wegmans Pharmacy, Ithaca, New York.9 Population Health Research Institute, Hamilton, ON, Canada.10 Duke Clinical Research Institute, Durham, NC.11 St. Luke's Roosevelt Hospital, Mt. Sinai School of Medicine, New York, NY.
BACKGROUND: Debate exists regarding the efficacy of â-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 â-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 and/or receiving aspirin/statin) or pre-reperfusion era trials. RESULTS: Sixty trials with 102003 patients satisfied the inclusion criteria. In the acute myocardial infarction trials, a significant interaction (Pinteraction=0.02) was noted such that â-blockers reduced mortality in the pre-reperfusion[Incident Rate Ratio (IRR)=0.86, 95% 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, â-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, â-blockers reduced myocardial infarction(IRR=0.72, 95% CI 0.62-0.83) (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) (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, â-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 guidelines should reconsider the strength of recommendations for â-blockers post myocardial infarction.
American Journal of Medicine, 2014, Vol 127, Issue 10, p. 939-953