Johner Nicolas, Branca Mattia, Carballo David, Baggio Stéphanie, Nanchen David, Tessitore Elena, Räber Lorenz, Lüscher Thomas Felix, Matter Christian M, Windecker Stephan, Rodondi Nicolas, Mach François, Gencer Baris
Cardiology Division, Geneva University Hospitals, Geneva, Switzerland.
CTU Bern, Department of Clinical Research, University of Bern, Bern, Switzerland.
Eur J Prev Cardiol. 2024 Oct 26. doi: 10.1093/eurjpc/zwae346.
The benefit of long-term beta-blocker therapy after acute coronary syndromes (ACS) without heart failure in the reperfusion era is uncertain. Two recent randomized trials found conflicting results. The present study assessed the safety of beta-blocker discontinuation within 12 months following ACS with LVEF ≥40%.
In a multicentre prospective real-world cohort (N=3,762) of patients hospitalized for ACS, patients with LVEF ≥40% and beta-blockers at discharge were included. Patients who continued beta-blockers at one year were compared with those who discontinued beta-blockers within 12 months post-ACS using target trial emulation and inverse probability weighting over an additional four-year follow-up. The primary endpoint was major adverse cardiovascular events (MACE), a composite of four-year cardiovascular death, myocardial infarction, stroke, transient ischemic attack, unplanned coronary revascularization, or unstable angina hospitalization.
Of 2,077 patients, 1,758 (85%) continued beta-blockers and 319 (15%) had discontinued beta-blockers at one year. The risk of primary endpoint was similar in both groups (14.1% versus 14.3% with beta-blocker discontinuation versus continuation; adjusted hazard ratio [aHR]=0.98; 95% confidence interval, 0.72-1.34, P=0.91). Subgroup analysis suggested a higher risk of primary endpoint with beta-blocker discontinuation after STEMI (aHR=1.46 [0.99-2.16]) compared to NSTEMI (aHR=0.70 [0.40-1.22], Pinteraction=0.033), whereas there was no interaction with LVEF (Pinteraction=0.68).
Beta-blocker discontinuation within 12 months following ACS with LVEF ≥40% was not associated with an increased risk of MACE compared to long-term beta-blocker therapy. Subgroup analysis suggested potential risk in STEMI patients. Discontinuing beta-blockers 12 months after ACS appears safe in patients with LVEF ≥40%, particularly after NSTEMI.
在再灌注时代，急性冠脉综合征（ACS）且无心力衰竭患者长期使用β受体阻滞剂治疗的获益尚不确定。最近两项随机试验得出了相互矛盾的结果。本研究评估了左心室射血分数（LVEF）≥40%的ACS患者在12个月内停用β受体阻滞剂的安全性。
在一个多中心前瞻性真实世界队列研究（N = 3762例）中，纳入因ACS住院且LVEF≥40%并在出院时使用β受体阻滞剂的患者。在额外四年的随访中，使用目标试验模拟和逆概率加权法，将一年时继续使用β受体阻滞剂的患者与ACS后12个月内停用β受体阻滞剂的患者进行比较。主要终点是主要不良心血管事件（MACE），即四年内心血管死亡、心肌梗死、中风、短暂性脑缺血发作、非计划性冠状动脉血运重建或不稳定型心绞痛住院的复合终点。
在2077例患者中，1758例（85%）在一年时继续使用β受体阻滞剂，319例（15%）停用β受体阻滞剂。两组主要终点风险相似（停用β受体阻滞剂组为14.1%，继续使用β受体阻滞剂组为14.3%；调整后风险比[aHR]=0.98；95%置信区间，0.72 - 1.34，P = 0.91）。亚组分析表明，与非ST段抬高型心肌梗死（NSTEMI）相比，ST段抬高型心肌梗死（STEMI）后停用β受体阻滞剂时主要终点风险更高（aHR = 1.46 [0.99 - 2.16]），而与LVEF无交互作用（交互作用P值 = 0.68）。
与长期使用β受体阻滞剂治疗相比，LVEF≥40%的ACS患者在12个月内停用β受体阻滞剂与MACE风险增加无关。亚组分析提示STEMI患者存在潜在风险。对于LVEF≥40%的患者，ACS后12个月停用β受体阻滞剂似乎是安全的，尤其是在NSTEMI后。
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