Chi Kuan-Yu, Lee Pei-Lun, Chowdhury Ishmum, Akman Zafer, Mangalesh Sridhar, Song Junmin, Satish Vikyath, Babapour Golsa, Kang Yi-No, Schwartz Rachel, Chang Yu, Borkowski Pawel, Michele Nanna, Damluji Abdulla A, Nanna Michael G
Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
Department of Medicine, Yale School of Medicine, New Haven, CT, USA.
Eur J Prev Cardiol. 2024 Sep 20. doi: 10.1093/eurjpc/zwae298.
The 2023 ESC guidelines for acute coronary syndrome note that contemporary data are heterogenous regarding beta-blockers (BB) use post-myocardial infarction (MI) in patients without reduced ejection fraction (EF) or heart failure (HF). We aimed to address the heterogeneity in contemporary data around BB post-MI in this population.
We searched 6 databases from Jan 1, 2000 to Sep 1, 2024 to identify contemporary studies enrolling MI patients without reduced EF (≤40%) or history of HF receiving BB at index MI, and comparing outcomes between BB users and non-users. The primary outcome was all-cause mortality. Secondary outcomes included major adverse cardiac and cerebrovascular events (MACCE) and cardiovascular (CV) mortality. Random-effects meta-analysis was conducted using the restricted maximum likelihood method.
There were 24 studies including 290,349 patients enrolled in the contemporary era. Overall, BB use was associated with a significant 11% reduction in all-cause mortality (HR, 0.89; 95% CI, 0.81 to 0.97; I2 = 40%; Figure 1), however with moderate-to-high statistical heterogeneity. Prespecified subgroup analyses demonstrate comparable all-cause mortality (HR, 0.99; 95% CI, 0.94 to 1.06; I2 = 0%), CV mortality (HR, 0.99; 95% CI, 0.85 to 1.15; I2 = 0%), and MACCE (HR, 1.24; 95% CI, 1.01 to 1.52; I2 = 0%) in patients with a 1-year event-free period, defined as no death, recurrent MI, or HF while on BB following index MI. In patients with no event-free period, meta-regression revealed that BB mortality benefits were modified by the study inclusion period (P = 0.01), reflecting a temporal trend of decreasing BB mortality benefits over time. Based on the temporal trend, in patients with preserved EF post-2010, BB exhibited no reduction in all-cause mortality (HR, 0.97; 95% CI, 0.90 to 1.04; I2 = 0%), but a non-significant trend towards increased CV mortality (HR, 1.29; 95% CI, 0.96 to 1.72; I2 = 0%) and a significant increase in MACCE (HR, 1.24; 95% CI, 1.01 to 1.52; I2 = 0%).
In the contemporary reperfusion era, BB may not confer additional mortality benefits beyond a 1-year event-free period post-MI in patients without reduced EF. Moreover, post-MI BB use was associated with detrimental effects in patients with preserved EF.
2023年欧洲心脏病学会（ESC）急性冠状动脉综合征指南指出，关于射血分数（EF）未降低或无心力衰竭（HF）的患者心肌梗死（MI）后使用β受体阻滞剂（BB），当代数据存在异质性。我们旨在解决该人群中当代关于MI后使用BB的数据异质性问题。
我们检索了6个数据库，时间跨度为2000年1月1日至2024年9月1日，以确定纳入EF未降低（≤40%）或无HF病史且在首次MI时接受BB治疗的MI患者的当代研究，并比较BB使用者和非使用者的结局。主要结局是全因死亡率。次要结局包括主要不良心脑血管事件（MACCE）和心血管（CV）死亡率。采用限制最大似然法进行随机效应荟萃分析。
当代共有24项研究，纳入290,349例患者。总体而言，使用BB与全因死亡率显著降低11%相关（风险比[HR]，0.89；95%置信区间[CI]，0.81至0.97；I² = 40%；图1），然而存在中度至高的统计学异质性。预先设定的亚组分析显示，在定义为首次MI后使用BB期间无死亡、复发性MI或HF的1年无事件期患者中，全因死亡率（HR，0.99；95% CI，0.94至1.06；I² = 0%）、CV死亡率（HR，0.99；95% CI，0.85至1.15；I² = 0%）和MACCE（HR，1.24；95% CI，1.01至1.52；I² = 0%）具有可比性。在无无事件期的患者中，荟萃回归显示BB的死亡率获益受研究纳入期影响（P = 0.01），反映出随着时间推移BB死亡率获益逐渐降低的时间趋势。基于该时间趋势，在2010年后EF保留的患者中，BB并未降低全因死亡率（HR，0.97；95% CI，0.90至1.04；I² = 0%），但CV死亡率有增加的非显著趋势（HR，1.29；95% CI，0.96至1.72；I² = 0%），且MACCE显著增加（HR，1.24；95% CI，1.01至1.52；I² = 0%）。
在当代再灌注时代，对于EF未降低的患者，MI后超过1年无事件期，BB可能不会带来额外的死亡率获益。此外，MI后使用BB与EF保留患者的有害影响相关。
