Beta-blocker discontinuation was associated with an increased risk of MACE (HR 2.26; 95% CI 1.78-2.87; p<0.01) compared to prolonged treatment, though restricted RCT analysis showed no difference.
Meta-Analysis (n=99,804)
Does beta-blocker discontinuation increase MACE and mortality in post-myocardial infarction patients with preserved LVEF compared to prolonged therapy?
Although pooled observational and trial data suggest beta-blocker discontinuation increases MACE and mortality in post-MI patients with preserved LVEF, RCT-only data shows no clear advantage of prolonged therapy.
Effect estimate: HR 2.26 (95% CI 1.78-2.87)
p-value: p=<0.01
Abstract Background Beta-blockers (BB) have long been a cornerstone in the management of post-myocardial infarction (MI). However, recent trials challenge the necessity of prolonged beta-blocker use, especially in patients with preserved left ventricular ejection fraction (LVEF). Purpose This systematic review and meta-analysis aimed to examine the clinical impact of beta-blocker continuation versus interruption in post-MI patients with preserved LVEF. Methods We conducted a comprehensive search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials to identify randomized controlled trials (RCT) and observational cohorts comparing BB long-term therapy or early discontinuation post-MI in patients without systolic dysfunction. The data were computed using the Hazard Ratio (HR) and Risk Ratio (RR). Statistical analysis utilized R version 4.2.2. Heterogeneity was assessed with I² statistics; p-values inferior to 0.05 and I² 25% were considered significant heterogeneity. The outcomes assessed included MACE (cardiovascular death, myocardial infarction, stroke or transient ischaemic attack, unplanned coronary revascularization, hospitalization for unstable angina or heart failure), all-cause mortality, cardiovascular death, heart failure (HF), hospitalization, MI, and stroke. Results A total of 11 studies (3 RCTs) were included, encompassing 99,804 participants, of whom 82% remained on chronic beta-blocker therapy. BB discontinuation was associated with an increased risk of MACE (HR 2.26; CI: 1.78–2.87; p 0.01; Figure 1) and all-cause mortality (HR 2.41; CI: 2.11–2.75; p 0.01; Figure 2) compared to prolonged treatment. Nevertheless, no significant differences were observed in cardiovascular death (RR 1.05; CI: 0.90–1.22; p = 0.528), HF-related hospitalization (RR 1.24; CI: 0.97–1.58; p = 0.091), recurrent infarction (RR 1.04; CI: 0.87–1.23; p = 0.682), or stroke incidence (RR 0.95; CI: 0.68–1.33; p = 0.768). The increase in MACE remains consistent when analyzing the subgroup that included only LVEF 50%. However, no significant disparities emerged between the groups in any measured endpoints when restricting the assessment to RCTs. Conclusion Our systematic review and meta-analysis suggest that while BB discontinuation is associated with increased MACE and mortality in post-MI patients without reduced LVEF, RCT shows no clear advantage of prolonged therapy.
Lucena et al. (Sat,) conducted a meta-analysis in Post-myocardial infarction with preserved LVEF (n=99,804). Beta-blocker discontinuation vs. Prolonged beta-blocker therapy was evaluated on MACE (cardiovascular death, myocardial infarction, stroke or transient ischaemic attack, unplanned coronary revascularization, hospitalization for unstable angina or heart failure) (HR 2.26, 95% CI 1.78-2.87, p=<0.01). Beta-blocker discontinuation was associated with an increased risk of MACE (HR 2.26; 95% CI 1.78-2.87; p<0.01) compared to prolonged treatment, though restricted RCT analysis showed no difference.