Effect of ?-Blockers Beyond 3 Years After Acute Myocardial Infarction.
ABSTRACT: BACKGROUND:The optimal duration of ?-blocker therapy in patients with acute myocardial infarction (AMI) is unknown. We aimed to evaluate the late effect of ?-blockers in patients with AMI. METHODS AND RESULTS:We enrolled all consecutive patients who presented with AMI at Seoul National University Bundang Hospital, between June 3, 2003 and February 24, 2015. The primary end point was 5-year all-cause mortality, depending on the use of ?-blockers at discharge, 1 year after AMI, and 3 years after AMI. Of 2592 patients, the prescription rates of ?-blockers were 72%, 69%, 63%, and 60% at discharge and 1, 3, and 5 years after AMI, respectively. The patients who were receiving ?-blocker therapy had more favorable clinical characteristics, such as younger age (62 versus 65 years; P<0.001). They received reperfusion therapy more often (92% versus 80%; P<0.001) than those without ?-blocker prescription. In the univariate analysis, the patients with ?-blocker prescription had lower 5-year mortality at all time points. In the Cox model after adjustment for significant covariates, ?-blocker prescription at discharge was associated with a 29% reduced mortality risk (hazard ratio, 0.71; 95% confidence interval, 0.55-0.90; P=0.006); however, ?-blocker prescriptions at 1 and 3 years after AMI were not associated with reduced mortality. CONCLUSIONS:The beneficial effect of ?-blocker therapy after AMI may be limited until 1 year after AMI. Whether late ?-blocker therapy beyond 1 year after AMI offers clinical benefits should be confirmed in further clinical trials.
Project description:BACKGROUND:Patients with chronic obstructive pulmonary disease (COPD) less often receive ?-blockers after acute myocardial infarction (AMI). This may influence their outcomes after AMI. This study evaluated the efficacy of ?-blockers after AMI in patients with COPD, compared with non-dihydropyridine calcium channel blockers (NDCCBs) and absence of these two kinds of treatment. METHODS AND RESULTS:We conducted a nationwide population-based cohort study using data retrieved from Taiwan National Health Insurance Research Database. We collected 28,097 patients with COPD who were hospitalized for AMI between January 2004 and December 2013. After hospital discharge, 24,056 patients returned to outpatient clinics within 14 days (the exposure window). Those who received both ?-blockers and NDCCBs (n = 302) were excluded, leaving 23,754 patients for analysis. Patients were classified into the ?-blocker group (n = 10,638, 44.8%), the NDCCB group, (n = 1,747, 7.4%) and the control group (n = 11,369, 47.9%) based on their outpatient prescription within the exposure window. The ?-blockers group of patients had lower overall mortality risks (adjusted hazard ratio [95% confidence interval]: 0.91 [0.83-0.99] versus the NDCCB group; 0.88 [0.84-0.93] versus the control group), but the risk of major adverse cardiac events within 1 year was not statistically different. ?-blockers decreased risks of re-hospitalization for COPD and other respiratory diseases by 12-32%. CONCLUSIONS:The use of ?-blockers after AMI was associated with a reduced mortality risk in patients with COPD. ?-blockers did not increase the risk of COPD exacerbations.
Project description:Beta-adrenergic receptor blockers are used in patients with coronary artery disease (CAD) to reduce the harmful effects of excessive adrenergic activation on the heart. However, there is limited evidence regarding the benefit of beta-blockers in the context of contemporary management following percutaneous coronary intervention (PCI). We used the nationwide South Korea National Health Insurance database to identify 87,980 patients with a diagnosis of either acute myocardial infarction (AMI; n?=?38,246) or angina pectoris (n?=?49,734) who underwent PCI between 2013 and 2017, and survived to be discharged from hospital. Beta-blockers were used in a higher proportion of patients with AMI (80.6%) than those with angina (58.9%). Over a median follow-up of 2.2 years (interquartile range 1.2–3.3 years) with the propensity-score matching analysis, the mortality risk was significantly lower in patients treated with a beta-blocker in the AMI group (HR: 0.78; 95% CI 0.69–0.87; p?<?0.001). However, the mortality risk was comparable regardless of beta-blocker use (HR: 1.07; 95% CI 0.98–1.16; p?=?0.10) in the angina group. The survival benefit associated with beta-blocker therapy was most significant in the first year after the AMI event.
Project description:OBJECTIVE:To assess the association between early and prolonged ? blocker treatment and mortality after acute myocardial infarction. DESIGN:Multicentre prospective cohort study. SETTING:Nationwide French registry of Acute ST- and non-ST-elevation Myocardial Infarction (FAST-MI) (at 223 centres) at the end of 2005. PARTICIPANTS:2679 consecutive patients with acute myocardial infarction and without heart failure or left ventricular dysfunction. MAIN OUTCOME MEASURES:Mortality was assessed at 30 days in relation to early use of ? blockers (?48 hours of admission), at one year in relation to discharge prescription, and at five years in relation to one year use. RESULTS:? blockers were used early in 77% (2050/2679) of patients, were prescribed at discharge in 80% (1783/2217), and were still being used in 89% (1230/1383) of those alive at one year. Thirty day mortality was lower in patients taking early ? blockers (adjusted hazard ratio 0.46, 95% confidence interval 0.26 to 0.82), whereas the hazard ratio for one year mortality associated with ? blockers at discharge was 0.77 (0.46 to 1.30). Persistence of ? blockers at one year was not associated with lower five year mortality (hazard ratio 1.19, 0.65 to 2.18). In contrast, five year mortality was lower in patients continuing statins at one year (hazard ratio 0.42, 0.25 to 0.72) compared with those discontinuing statins. Propensity score and sensitivity analyses showed consistent results. CONCLUSIONS:Early ? blocker use was associated with reduced 30 day mortality in patients with acute myocardial infarction, and discontinuation of ? blockers at one year was not associated with higher five year mortality. These findings question the utility of prolonged ? blocker treatment after acute myocardial infarction in patients without heart failure or left ventricular dysfunction.Trial registration Clinical trials NCT00673036.
Project description:BACKGROUND AND OBJECTIVES:Whether beta blockers favorably impact the clinical outcome in patients with acute myocardial infarction (AMI) remains in debate. We investigated the impact of beta blocker on major clinical outcomes during 2 years after percutaneous coronary intervention (PCI) in patients with AMI. METHODS:All patients with the first AMI treated with PCI for the period of 2005 to 2014 from the Korean National Health Insurance Service claims database were enrolled. We defined the regular user as medication possession ratio (MPR) ?80% and non-user as MPR=0%. We compared the occurrence of all cause death, myocardial infarction (MI) and stroke according to adherence of beta-blockers. A 1:1 propensity score-matching was conducted to adjust for between-group differences. RESULTS:We identified a total 81,752 patients with met eligible criteria. At discharge, 63,885 (78%) patients were prescribed beta blockers. For 2 years follow up period, regular users were 53,991 (66%) patients, non-users were 10,991 (13%). In the propensity score matched population, regular use of beta blocker was associated with a 36% reduced risk of composite adverse events (all death, MI or stroke) (hazard ratio [HR], 0.636; 95% confidence interval [CI], 0.555-0.728; p<0.001). Compared to no use of beta blocker, regular use significantly reduced all death (HR, 0.736; 95% CI, 0.668-0.812; p<0.001), MI (HR, 0.729; 95% CI, 0.611-0.803; p<0.001) and stroke (HR, 0.717; 95% CI, 0.650-0.791; p<0.001). CONCLUSIONS:Prescription of beta blocker in patients with AMI after PCI was sequentially increased. Continuous regular use of beta blocker for 2 years after AMI reduced major adverse events compared to no use of beta blocker.
Project description:Background Many hospitalized patients with heart failure and reduced ejection fraction ( HF r EF ) have a slow heart rate at discharge, and the effect of ?-blockers may be reduced in those patients. We sought to examine the variable effect of ?-blockers on clinical outcomes according to the discharge heart rate of hospitalized HF r EF patients. Methods and Results The KorAHF (Korean Acute Heart Failure) registry consecutively enrolled 5625 patients hospitalized for acute heart failure. In this analysis, we included patients with HF r EF (left ventricular ejection fraction ?40%). Slow heart rate was defined as <70 beats per minute regardless of the use of ?-blockers. The primary outcome was 1-year all-cause postdischarge death according to heart rate. Among 2932 patients with HF r EF , 840 (29%) had a slow heart rate and 56% received ?-blockers at discharge. Patients with slow heart rates were older and had lower 1-year mortality than those with high heart rates ( P<0.001). A significant interaction between discharge heart rate and ?-blocker use was observed ( P<0.001 for interaction). When stratified, only patients without a ?-blocker prescription and with a high heart rate showed higher 1-year mortality. In a Cox-proportional hazards regression analysis, ?-blocker prescription at discharge was associated with 24% reduced risk for 1-year mortality in patients with high heart rates (hazard ratio: 0.76; 95% CI, 0.61-0.95) but not in those with slow heart rates (hazard ratio: 1.02; 95% CI, 0.68-1.55). Conclusions Many patients with acute heart failure have slow discharge heart rates, and ?-blockers may have a limited effect on HF r EF and slow discharge heart rate. Clinical Trial Registration URL : http://www.clinicaltrial.gov . Unique identifier: NCT 01389843.
Project description:BACKGROUND:The evidence-based beta-blockers carvedilol, bisoprolol, and metoprolol succinate reduce mortality and hospitalizations among patients with heart failure with reduced ejection fraction (HFrEF). Use of these medications is not well described in the general population of patients with HFrEF, especially among patients with potential contraindications. OBJECTIVES:Our goal was to describe the patterns of prescription fills for carvedilol, bisoprolol, and metoprolol succinate among Medicare beneficiaries hospitalized for HFrEF, as well as to estimate the associations between specific contraindications for beta-blocker therapy and those patterns. METHODS AND RESULTS:With the use of the cohort of 15,205 Medicare beneficiaries hospitalized for HFrEF from 2007 to 2013 in the 5% Medicare random sample, we described prescription fills (30 days after discharge) and dosage patterns (1 year after discharge) for beta-blockers. By means of of Fine and Gray competing risk models, we estimated the associations between potential contraindications (hypotension, chronic obstructive pulmonary disease [COPD], asthma, and syncope) and prescription fill and dosing patterns while adjusting for demographics, comorbidities, and health care utilization. For beneficiaries who did not die or readmitted to the hospital, 38% of hospitalizations were followed by a prescription fill for an evidence-based beta-blocker within 30 days, 12% were followed by prescription fills for at least 50% of the recommended dose of an evidence-based beta-blocker within 1 year, and 9% were followed by a prescription fill for an up-titrated dose of an evidence-based beta-blocker within 1 year. The prevalence of the contraindications were 21% for hypotension, 48% for COPD, 15% for asthma, and 12% for syncope. Among beneficiaries who did not fill a prescription for an evidence-based beta-blocker within 30 days, 67% had at least 1 of these contraindications. Hypotension, COPD, and syncope were each associated with a ?10% lower risk of filling a prescription for an evidence-based beta-blocker. CONCLUSIONS:Prescription fill and up-titration rates for evidence-based beta-blockers are low among Medicare beneficiaries with HFrEF, but contraindications explain only a minor part of these low rates.
Project description:BACKGROUND:For acute myocardial infarction (AMI) without heart failure (HF), it is unclear if ?-blockers are associated with reduced mortality. OBJECTIVES:The goal of this study was to determine the association between ?-blocker use and mortality in patients with AMI without HF or left ventricular systolic dysfunction (LVSD). METHODS:This cohort study used national English and Welsh registry data from the Myocardial Ischaemia National Audit Project. A total of 179,810 survivors of hospitalization with AMI without HF or LVSD, between January 1, 2007, and June 30, 2013 (final follow-up: December 31, 2013), were assessed. Survival-time inverse probability weighting propensity scores and instrumental variable analyses were used to investigate the association between the use of ?-blockers and 1-year mortality. RESULTS:Of 91,895 patients with ST-segment elevation myocardial infarction and 87,915 patients with non-ST-segment elevation myocardial infarction, 88,542 (96.4%) and 81,933 (93.2%) received ?-blockers, respectively. For the entire cohort, with >163,772 person-years of observation, there were 9,373 deaths (5.2%). Unadjusted 1-year mortality was lower for patients who received ?-blockers compared with those who did not (4.9% vs. 11.2%; p < 0.001). However, after weighting and adjustment, there was no significant difference in mortality between those with and without ?-blocker use (average treatment effect [ATE] coefficient: 0.07; 95% confidence interval [CI]: -0.60 to 0.75; p = 0.827). Findings were similar for ST-segment elevation myocardial infarction (ATE coefficient: 0.30; 95% CI: -0.98 to 1.58; p = 0.637) and non-ST-segment elevation myocardial infarction (ATE coefficient: -0.07; 95% CI: -0.68 to 0.54; p = 0.819). CONCLUSIONS:Among survivors of hospitalization with AMI who did not have HF or LVSD as recorded in the hospital, the use of ?-blockers was not associated with a lower risk of death at any time point up to 1 year. (?-Blocker Use and Mortality in Hospital Survivors of Acute Myocardial Infarction Without Heart Failure; NCT02786654).
Project description:Acute respiratory failure (ARF) is responsible for about one-third of intensive care unit (ICU) admissions and is associated with adverse outcomes. Predictors of short- and long-term outcomes in unselected ICU-patients with ARF are ill-defined. The purpose of this analysis was to determine predictors of in-hospital and one-year mortality and assess the effects of oral beta-blockers in unselected ICU patients with ARF included in the BASEL-II-ICU study.The BASEL II-ICU study was a prospective, multicenter, randomized, single-blinded, controlled trial of 314 (mean age 70 (62 to 79) years) ICU patients with ARF evaluating impact of a B-type natriuretic peptide- (BNP) guided management strategy on short-term outcomes.In-hospital mortality was 16% (51 patients) and one-year mortality 41% (128 patients). Multivariate analysis assessed that oral beta-blockers at admission were associated with a lower risk of both in-hospital (HR 0.33 (0.14 to 0.74) P = 0.007) and one-year mortality (HR 0.29 (0.16 to 0.51) P = 0.0003). Kaplan-Meier analysis confirmed the lower mortality in ARF patients when admitted with oral beta-blocker and further shows that the beneficial effect of oral beta-blockers at admission holds true in the two subgroups of patients with ARF related to cardiac or non-cardiac causes. Kaplan-Meier analysis also shows that administration of oral beta-blockers before hospital discharge gives striking additional beneficial effects on one-year mortality.Established beta-blocker therapy appears to be associated with a reduced mortality in ICU patients with acute respiratory failure. Cessation of established therapy appears to be hazardous. Initiation of therapy prior to discharge appears to confer benefit. This finding was seen regardless of the cardiac or non-cardiac etiology of respiratory failure.clinicalTrials.gov Identifier: NCT00130559.
Project description:<h4>Aims</h4>The aim of this study is to investigate the association between adherence to beta-blocker treatment after a first acute myocardial infarction (AMI) and long-term risk of heart failure (HF) and death.<h4>Methods and results</h4>All patients admitted for a first AMI included in the nationwide Swedish web-system for enhancement and development of evidence-based care in heart disease evaluated according to recommended therapies register between 2005 and 2010 were eligible (n = 71 638). After exclusion of patients who died in-hospital, patients with previous HF, patients with unknown left ventricular ejection fraction (EF), and patients who died during the first year after the index event, 38 608 patients remained in the final analysis. Adherence to prescribed beta-blockers was determined for 1 year after the index event using the national registry for prescribed drugs and was measured as proportion of days covered, the ratio between the numbers of days covered by the dispensed prescriptions and number of days in the period. As customary, a threshold level for proportion of days covered ?80% was used to classify patients as adherent or non-adherent. At discharge 90.6% (n = 36 869) of all patients were prescribed a beta-blocker. Among 38 608 1 year survivors, 31.1% (n = 12 013) were non-adherent to beta-blockers. Patients with reduced EF with and without HF were more likely to remain adherent to beta-blockers at 1-year compared with patients with normal EF without HF (NEF). Being married/cohabiting and having higher income level, hypertension, ST-elevation MI, and percutaneous coronary intervention were associated with better adherence. Adherence was independently associated with lower all-cause mortality [hazard ratio (HR) 0.77, 95% confidence interval [CI] 0.71-0.84] and a lower risk for the composite of HF readmission/death, (HR 0.83, 95% CI 0.78-0.89, P value <0.001) during the subsequent 4 years of follow up. These associations were favourable but less apparent in patients with HFNEF and NEF.<h4>Conclusions</h4>Nearly one in three AMI patients was non-adherent to beta-blockers within the first year. Adherence was independently associated with improved long-term outcomes; however, uncertainty remains for patients with HFNEF and NEF.
Project description:Importance:Although ?-blockers are a mainstay of treatment after acute myocardial infarction (AMI), these medications are commonly not prescribed for older nursing home residents after AMI, in part owing to concerns about potential functional harms and uncertainty of benefit. Objective:To study the association of ?-blockers after AMI with functional decline, mortality, and rehospitalization among long-stay nursing home residents 65 years or older. Design, Setting, and Participants:This cohort study of nursing home residents with AMI from May 1, 2007, to March 31, 2010, used national data from the Minimum Data Set, version 2.0, and Medicare Parts A and D. Individuals with ?-blocker use before AMI were excluded. Propensity score-based methods were used to compare outcomes in people who did vs did not initiate ?-blocker therapy after AMI hospitalization. Main Outcomes and Measures:Functional decline, death, and rehospitalization in the first 90 days after AMI. Functional status was measured using the Morris scale of independence in activities of daily living. Results:The initial cohort of 15?720 patients (11?140 women [70.9%] and 4580 men [29.1%]; mean [SD] age, 83  years) included 8953 new ?-blocker users and 6767 nonusers. The propensity-matched cohort included 5496 new users of ?-blockers and an equal number of nonusers for a total cohort of 10?992 participants (7788 women [70.9%]; 3204 men [29.1%]; mean [SD] age, 84  years). Users of ?-blockers were more likely than nonusers to experience functional decline (odds ratio [OR], 1.14; 95% CI, 1.02-1.28), with a number needed to harm of 52 (95% CI, 32-141). Conversely, ?-blocker users were less likely than nonusers to die (hazard ratio [HR], 0.74; 95% CI, 0.67-0.83) and had similar rates of rehospitalization (HR, 1.06; 95% CI, 0.98-1.14). Nursing home residents with moderate or severe cognitive impairment or severe functional dependency were particularly likely to experience functional decline from ?-blockers (OR, 1.34; 95% CI, 1.11-1.61 and OR, 1.32; 95% CI, 1.10-1.59, respectively). In contrast, little evidence of functional decline due to ?-blockers was found in participants with intact cognition or mild dementia (OR, 1.03; 95% CI, 0.89-1.20; P?=?.03 for effect modification) or in those in the best (OR, 0.99; 95% CI, 0.77-1.26) and intermediate (OR, 1.05; 95% CI, 0.86-1.27) tertiles of functional independence (P?=?.06 for effect modification). Mortality benefits of ?-blockers were similar across all subgroups. Conclusions and Relevance:Use of ?-blockers after AMI is associated with functional decline in older nursing home residents with substantial cognitive or functional impairment, but not in those with relatively preserved mental and functional abilities. Use of ?-blockers yielded a considerable mortality benefit in all groups.