September 16, 2020Scientific Reports22 citationsOpen Access
Beta-blockers and renin-angiotensin system inhibitors in acute myocardial infarction managed with inhospital coronary revascularization
Key Result
Combined use of beta-blockers and ACEI/ARB at discharge in patients with acute myocardial infarction managed with revascularization was associated with a reduced incidence of 12-month MACE (HR 0.70).
Study Design
Type
Cohort (n=15,073)
Multicenter
Yes
Structured PICO
Does the prescription of beta-blockers and/or ACEI/ARB at discharge reduce 12-month MACE and mortality in patients with acute myocardial infarction managed with inhospital coronary revascularization?
P
Population
15,073 patients with acute myocardial infarction (STEMI or non-STEMI) who underwent inhospital coronary revascularization (PCI or CABG) during the index hospitalization, median age 58, 83.2% male, from the Singapore Myocardial Infarct Registry.
I
Intervention
Beta-blockers (BB) and/or angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) prescribed at discharge.
C
Comparator
Patients not prescribed beta-blockers and/or ACEI/ARB at discharge (reference group).
O
Outcome
Major adverse cardiovascular events (MACE), defined as a composite of all-cause mortality, hospitalization for heart failure, or hospitalization for myocardial infarction at 12 months.composite
In patients with acute myocardial infarction undergoing inhospital revascularization, prescription of both beta-blockers and ACEI/ARBs at discharge is associated with significantly lower 12-month mortality and MACE, regardless of LVEF.
Main Result
Effect estimate: HR 0.70 (95% CI 0.57-0.86)
Absolute Event Rate: 10.6% vs 15.1%
Limitations
- Nonrandomized nature of the study could have resulted in selection bias in treatment allocation
- Unmeasured and unknown confounders such as unrecorded co-morbidities, medication adherence, and socioeconomic status
- Specific reasons for contraindications to medications were not systematically captured
- Lack of data on the specific type of beta-blocker and/or ACEI/ARB initiated
- No longitudinal data on up-titration of dosage, cessation of therapy, and long-term adherence
- Study cohort only included patients up to year 2013
- Ethnic distribution of the study cohort may limit generalization to other populations
- Nonrandomized nature resulting in selection bias in treatment allocation
- Unmeasured and unknown confounders including unrecorded co-morbidities, medication adherence, and socioeconomic status
Abstract
Pivotal trials of beta-blockers (BB) and angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) in acute myocardial infarction (AMI) were largely conducted prior to the widespread adoption of early revascularization. A total of 15,073 patients with AMI who underwent inhospital coronary revascularization from January 2007 to December 2013 were analyzed. At 12 months, BB was significantly associated with a lower incidence of major adverse cardiovascular events (MACE, adjusted HR 0.80, 95% CI 0.70-0.93) and all-cause mortality (adjusted HR 0.69, 95% CI 0.55-0.88), while ACEI/ARB was significantly associated with lower all-cause mortality (adjusted HR 0.80, 95% CI 0.66-0.98) and heart failure (HF) hospitalization (adjusted HR 0.80, 95% CI 0.68-0.95). Combined BB and ACEI/ARB use was associated with the lowest incidence of MACE (adjusted HR 0.70, 95% CI 0.57-0.86), all-cause mortality (adjusted HR 0.55, 95% CI 0.40-0.77) and HF hospitalization (adjusted HR 0.64, 95% CI 0.48-0.86). This were consistent for left ventricular ejection fraction < 50% or ≥ 50%. In conclusion, in AMI managed with revascularization, both BB and ACEI/ARB were associated with a lower incidence of 12-month all-cause mortality. Combined BB and ACEI/ARB was associated with the lowest incidence of all-cause mortality and HF hospitalization.
Cite This Study
Sim et al. (2020) conducted a cohort in Acute myocardial infarction (n=15,073). Beta-blockers and ACEI/ARB vs. No beta-blockers and no ACEI/ARB was evaluated on Major adverse cardiovascular events (MACE) (HR 0.70, 95% CI 0.57-0.86). Combined use of beta-blockers and ACEI/ARB at discharge in patients with acute myocardial infarction managed with revascularization was associated with a reduced incidence of 12-month MACE (HR 0.70).