The Art of Prescribing β-Blockers After Myocardial Infarction

HomeCirculation: Cardiovascular InterventionsVol. 14, No. 4The Art of Prescribing β-Blockers After Myocardial Infarction Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessEditorialPDF/EPUBThe Liyew Desta, MD, PhD, Sergio Raposeiras-Roubin, PhD and Borja Ibanez, DestaLiyew Desta Karolinska University Hospital, Solna, Stockholm, Sweden, Email E-mail Address: [email protected] https://orcid.org/0000-0002-1950-4159 Department Cardiology, Sweden (L.D.). Search for more papers by this author , Raposeiras-RoubinSergio Raposeiras-Roubin https://orcid.org/0000-0002-6462-4715 Clinical Research Department, Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (S.R.-R., B.I.). Cardiology Hospital Álvaro Cunqueiro, Vigo, (S.R.-R.). IbanezBorja Ibanez Correspondence to: Cardiovasculares Carlos III, c/Melchor Fernández Almagro 3, 28029 Spain, https://orcid.org/0000-0002-5036-254X IIS-Fundación Jiménez Díaz (B.I.). CIBER Enfermedades Originally published20 Apr 2021https://doi.org/10.1161/CIRCINTERVENTIONS.121.010720Circulation: Interventions. 2021;14:e010720This article is a commentary on the followingLeft Ventricular Ejection Fraction 1 Year Acute Identifies Benefits Long-Term Use β-BlockersSee Article Park et alMedicine an example integration science art. (mainly trials) allows establish treatment algorithms (with categorical decisions) based specific population sets. However, in daily practice, many times, patients have clinical profile different from those included trials who founded guidelines. Individualized available evidence complex art that physicians practice every day. One clear balance between prescription β-blockers experienced myocardial infarction (MI) do not reduced left ventricular ejection fraction (LVEF). Most leading general recommendation prescribing after MI1 was generated at time where reperfusion or revascularization implemented coadjuvant pharmacological therapy (antithrombotic, lipid lowering, etc) very limited.2 Old prospective randomized demonstrated long-term with MI improves outcome lower mortality about 20%. these trials, mostly 1980s, large MIs which dysfunction common antedate modern medical therapy. Thanks advances invasive management therapy, prognosis has been significantly improved.3 While benefits LVEF (≤40%) well several executed 21st century,4 question whether are still beneficial new scenario absence heart failure dysfunction.There scarce value maintenance preserved treated according current standards, including reperfusion, complete revascularization, potent antithrombotics aggressive lowering therapies. In meta-analysis, stratifying into prereperfusion era, did reduce era.5 A recent study examined association adherence β-blocker SWEDEHEART registry (Swedish Web-System Enhancement Development Evidence-Based Care Heart Disease Evaluated According Recommended Therapies) showed significant benefit survival risk late-onset 4 years index event while less obvious albeit positive trend adjusting background factors.6Despite widespread use overall tolerability β-blockers, drugs some side effects. The most frequent asthenia erectile dysfunction. addition, hypertension (not MI), coronary events,7 but their associated increased stroke when compared other treatments. also shown increase new-onset diabetes. When nondiuretic antihypertensive drugs, all-cause diabetes.8,9In years, only testing context focused acute administration during ongoing ST-segment–elevation (STEMI). METOCARD-CNIC trial (Metoprolol Cardioprotection During Infarction) intravenous metoprolol anterior STEMI reduces size infarction,10 presence microvascular obstruction injury,11 LVEF.12 Metoprolol exerts its effects specially there delay diagnosis reperfusion,13 probably delaying progression ischemic injury.14 Of note, shared β-blockers.15 test since all received them day onward. Other performed era short-term STEMI.4,16Given lack post-MI without observational studies tried address highly relevant issue. Unfortunately, results yielded opposite conclusions, suggesting benefit17–19 others they no benefit.20,21 Due nature studies, given indication guidelines, bias high. particular, existence confounding factor present random instead patients’ characteristics, especially characteristics outcome. Some randomness needed ensure individuals identical can be observed both states, something occur any studies. chance solving execution adequately sized trials. Currently, Europe: REBOOT-CNIC (Treatment With Beta-Blockers Without Reduced Fraction; https://www.clinicaltrials.gov; unique identifier: NCT03596385), REDUCE-SWEDEHEART (https://www.clinicaltrials.gov; NCT03278509), BETAMI (Betablocker Treatment Patients Left Systolic Function; NCT03646357), DANBLOCK (Danish Trial Beta Blocker NCT03778554). These expected end 2024.In issue journal, analysis regarded KAMIR-NIH registry, 13 104 2011 2015, presents data regarding (ie, beyond year) 1-year LVEF.22 From 1659 were dead lost follow-up year thus excluded analysis. An additional 7437 because available. Thus, total 4008 comprise population. Eighty-six percent discharged 79% year. At year, 1001 had <50% (83% discharge 80% year), 3007 ≥50% (87% year). shows improve 3-year regardless baseline LVEF. survivors 2 later improved <50%. <50%, cumulative incidence events 3 withdrawn anytime higher than kept β-blockers. line showing low should long term. Conversely, ≥50%, fact alive precludes definite answer safely fact, we know if first contrast all. Another interesting finding interaction LVEF) This result interpreted caution categorization (<50% ≥50%) echocardiography troublesome values close 50%. variability technique (especially environment) variable patient. There 743 information how number subjects versus unfortunately provided.In summary, presented hypothesis generating solve withdraw MI. regard, AβYSS trial23 (Beta Interruption Uncomplicated Infarction; NCT03498066) will randomize 3700 >6 months before maintain them. Indeed, strength favor against remains uncertain underlining need robust reliable beyond.Sources FundingDr supported European Commission (ERC-CoG grant 819775), Spanish Ministry Science Innovation (MCN; ‘RETOS 2019’ PID2019-107332RB-I00). CNIC ISCIII, Ministerio Ciencia e Innovación, Pro Foundation.Disclosures None.FootnotesThe opinions expressed necessarily editors American Association.For Sources Funding Disclosures, see page 401.Correspondence protected]esLiyew liyew.[email protected]seReferences1. B, James S, Agewall Antunes MJ, Bucciarelli-Ducci C, Bueno H, Caforio ALP, Crea F, Goudevenos JA, Halvorsen al.; ESC Scientific Document Group. 2017 guidelines presenting ST-segment elevation: task force elevation Society (ESC).Eur J. 2018; 39:119–177. doi: 10.1093/eurheartj/ehx393CrossrefMedlineGoogle Scholar2. Freemantle N, Cleland J, Young P, Mason Harrison Blockade infarction: systematic review meta regression analysis.BMJ. 1999; 318:1730–1737. 10.1136/bmj.318.7200.1730CrossrefMedlineGoogle Scholar3. L, Jernberg T, Löfman I, Hofman-Bang Hagerman Spaak Persson H. Incidence, temporal trends, prognostic impact complicating infarction. 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