Early anti-inflammatory therapy in acute myocardial infarction: A network meta-analysis of timing-dependent effects in 23 randomized trials and 28,220 patients.

BACKGROUND AND AIMS

The timing of anti-inflammatory therapy in acute myocardial infarction (AMI) may be critical, yet has not been systematically assessed. While several agents have shown benefit in secondary prevention, their efficacy during the early inflammatory phase of AMI remains uncertain. This study evaluated the effectiveness of anti-inflammatory therapies in AMI and whether early initiation within 24 h of symptom onset modifies clinical outcomes.

METHODS

We conducted a network meta-analysis of 23 randomized controlled trials including 28,220 patients with AMI. Interventions included colchicine, anakinra (IL-1β inhibitor), tocilizumab (IL-6 inhibitor), varespladib (PLA2 inhibitor), losmapimod (p38 MAPK inhibitor), cyclosporine (mitochondrial pore inhibitor), and pexelizumab (complement C5 inhibitor). Primary outcomes were major adverse cardiovascular events (MACE), heart failure (HF), and ischemic events. Treatment effects were summarized as incidence rate ratios (IRRs), defined as the ratio of incidence rates between intervention and control groups. Subgroup analyses stratified trials by treatment initiation ≤24 h vs > 24 h from symptom onset.

RESULTS

Colchicine significantly reduced MACE ([IRR] 0.71; 95 % confidence interval [CI] 0.53-0.97) and ischemic events (IRR 0.65; 95 % CI 0.43-0.98). Anakinra reduced HF events (IRR 0.38; 95 % CI 0.16-0.89). These effects were observed exclusively when treatment was initiated within 24 h. No benefit was seen with delayed therapy, and no other intervention showed clinical efficacy. Safety outcomes, including infection risk, were neutral across treatments.

CONCLUSIONS

This network meta-analysis demonstrates that anti-inflammatory therapy improves outcomes in AMI only when initiated early. Colchicine and anakinra were the only effective agents, highlighting a narrow therapeutic window and supporting a time-sensitive approach to inflammation-targeted treatment in AMI.