β受体阻滞剂用于心肌梗死的临床结局：随机试验的荟萃分析

Clinical outcomes with β-blockers for myocardial infarction: a meta-analysis of randomized trials.

作者信息

Bangalore Sripal, Makani Harikrishna, Radford Martha, Thakur Kamia, Toklu Bora, Katz Stuart D, DiNicolantonio James J, Devereaux P J, Alexander Karen P, Wetterslev Jorn, Messerli Franz H

机构信息

New York University School of Medicine, New York, NY.

St. Luke's Roosevelt Hospital, Mt. Sinai School of Medicine, New York, NY.

出版信息

Am J Med. 2014 Oct;127(10):939-53. doi: 10.1016/j.amjmed.2014.05.032. Epub 2014 Jun 11.

DOI:10.1016/j.amjmed.2014.05.032

PMID:24927909

Abstract

BACKGROUND

Debate exists about the efficacy of β-blockers in myocardial infarction and their required duration of usage in contemporary practice.

METHODS

We conducted a MEDLINE/EMBASE/CENTRAL search for randomized trials evaluating β-blockers in myocardial infarction enrolling at least 100 patients. The primary outcome was all-cause mortality. Analysis was performed stratifying trials into reperfusion-era (> 50% undergoing reperfusion or receiving aspirin/statin) or pre-reperfusion-era trials.

RESULTS

Sixty trials with 102,003 patients satisfied the inclusion criteria. In the acute myocardial infarction trials, a significant interaction (Pinteraction = .02) was noted such that β-blockers reduced mortality in the pre-reperfusion (incident rate ratio [IRR] 0.86; 95% confidence interval [CI], 0.79-0.94) but not in the reperfusion era (IRR 0.98; 95% CI, 0.92-1.05). In the pre-reperfusion era, β-blockers reduced cardiovascular mortality (IRR 0.87; 95% CI, 0.78-0.98), myocardial infarction (IRR 0.78; 95% CI, 0.62-0.97), and angina (IRR 0.88; 95% CI, 0.82-0.95), with no difference for other outcomes. In the reperfusion era, β-blockers reduced myocardial infarction (IRR 0.72; 95% CI, 0.62-0.83) (number needed to treat to benefit [NNTB] = 209) and angina (IRR 0.80; 95% CI, 0.65-0.98) (NNTB = 26) at the expense of increase in heart failure (IRR 1.10; 95% CI, 1.05-1.16) (number needed to treat to harm [NNTH] = 79), cardiogenic shock (IRR 1.29; 95% CI, 1.18-1.41) (NNTH = 90), and drug discontinuation (IRR 1.64; 95% CI, 1.55-1.73), with no benefit for other outcomes. Benefits for recurrent myocardial infarction and angina in the reperfusion era appeared to be short term (30 days).

CONCLUSIONS

In contemporary practice of treatment of myocardial infarction, β-blockers have no mortality benefit but reduce recurrent myocardial infarction and angina (short-term) at the expense of increase in heart failure, cardiogenic shock, and drug discontinuation. The guideline authors should reconsider the strength of recommendations for β-blockers post myocardial infarction.

摘要

背景

关于β受体阻滞剂在心肌梗死治疗中的疗效及其在当代临床实践中的使用时长存在争议。

方法

我们在MEDLINE/EMBASE/CENTRAL数据库中检索了评估β受体阻滞剂用于心肌梗死治疗且纳入至少100例患者的随机试验。主要结局为全因死亡率。分析时将试验分为再灌注时代（>50%患者接受再灌注治疗或服用阿司匹林/他汀类药物）或再灌注前时代的试验。

结果

60项试验共纳入102,003例患者，满足纳入标准。在急性心肌梗死试验中，观察到显著的交互作用（P交互作用 = 0.02），即β受体阻滞剂在再灌注前时代可降低死亡率（发生率比[IRR] 0.86；95%置信区间[CI]，0.79 - 0.94），但在再灌注时代则无此作用（IRR 0.98；95% CI，0.92 - 1.05）。在再灌注前时代，β受体阻滞剂可降低心血管死亡率（IRR 0.87；95% CI，0.78 - 0.98）、心肌梗死发生率（IRR 0.78；95% CI，0.62 - 0.97）和心绞痛发生率（IRR 0.88；95% CI，0.82 - 0.95），对其他结局无影响。在再灌注时代，β受体阻滞剂可降低心肌梗死发生率（IRR 0.72；95% CI，0.62 - 0.83）（需治疗获益人数[NNTB] = 209）和心绞痛发生率（IRR 0.80；95% CI，0.65 - 0.98）（NNTB = 26）但代价是心力衰竭发生率增加（IRR 1.10；95% CI，1.05 - 1.16）（需治疗危害人数[NNTH] = 79）、心源性休克发生率增加（IRR 1.29；95% CI，1.18 - 1.41）（NNTH = 90）以及药物停用率增加（IRR 1.64；95% CI，1.55 - 1.73），对其他结局无益处。再灌注时代β受体阻滞剂对复发性心肌梗死和心绞痛的获益似乎是短期的（30天）。