What is the clinical evidence from this study?

Study design: Cohort. Population: Acute myocardial infarction (n=15073). Intervention: Beta-blockers and ACEI/ARB vs. No beta-blockers and no ACEI/ARB. Primary outcome: Major adverse cardiovascular events (MACE) (HR 0.70, 95% CI 0.57-0.86).

September 16, 2020Open 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?

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.

Intervention

Beta-blockers (BB) and/or angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) prescribed at discharge.

Comparator

Patients not prescribed beta-blockers and/or ACEI/ARB at discharge (reference group).

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

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.

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