Routine beta-blocker therapy after acute coronary syndromes: The end of an era?

IF 4.4 3区医学 Q1 MEDICINE, GENERAL & INTERNAL

European Journal of Clinical Investigation Pub Date : 2024-09-10 DOI:10.1111/eci.14309

Nicolas Johner, Baris Gencer, Marco Roffi

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引用次数: 0

Abstract

Background

Beta-blocker therapy, a treatment burdened by side effects including fatigue, erectile dysfunction and depression, was shown to reduce mortality and cardiovascular events after acute coronary syndromes (ACS) in the pre-coronary reperfusion era. Potential mechanisms include protection from ventricular arrhythmias, increased ischaemia threshold and prevention of left ventricular (LV) adverse remodelling. With the advent of early mechanical reperfusion and contemporary pharmacologic secondary prevention, the benefit of beta-blockers after ACS in the absence of LV dysfunction has been challenged.

Methods

The present narrative review discusses the contemporary evidence based on searching the PubMed database and references in identified articles.

Results

Recently, the REDUCE-AMI trial—the first adequately powered randomized trial in the reperfusion era to test beta-blocker therapy after myocardial infarction with preserved left ventricular ejection fraction (LVEF)—showed no benefit on the composite of all-cause death or myocardial infarction over a median 3.5-year follow-up. While the benefit of beta-blockers in patients with reduced LVEF remains undisputed, their value in post-ACS patients with mildly reduced systolic function (LVEF 41%–49%) has not been studied in contemporary randomized trials; in this setting, observational studies have suggested a reduction in cardiovascular events with these agents. The adequate duration of beta-blocker therapy remains unknown, but observational data suggests that any mortality benefit may be lost beyond 1–12 months after ACS in patients with LVEF >40%.

Conclusion

We believe that there is sufficient evidence to abandon routine beta-blocker prescription in post-ACS patients with preserved LV systolic function.

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急性冠状动脉综合征后常规β-受体阻滞剂治疗：一个时代的终结？

背景在冠状动脉再灌注前的时代，β-受体阻滞剂疗法被证明可降低急性冠状动脉综合征（ACS）后的死亡率和心血管事件，但这种疗法的副作用包括疲劳、勃起功能障碍和抑郁。其潜在机制包括防止室性心律失常、提高缺血阈值和预防左心室不良重塑。随着早期机械性再灌注和现代药物二级预防的出现，在没有左心室功能障碍的情况下，ACS 后使用β-受体阻滞剂的益处受到了质疑。方法本叙事性综述在搜索 PubMed 数据库和已确定文章的参考文献的基础上讨论了当代证据。结果最近，REDUCE-AMI 试验--再灌注时代第一项对左心室射血分数（LVEF）保留的心肌梗死后β-受体阻滞剂治疗进行测试的充分有效随机试验--在中位 3.5 年的随访中未显示出全因死亡或心肌梗死的综合获益。虽然β-受体阻滞剂对 LVEF 降低的患者的益处仍是毋庸置疑的，但其对收缩功能轻度降低（LVEF 41%-49%）的 ACS 后患者的价值尚未在当代随机试验中进行研究；在这种情况下，观察性研究表明这些药物可减少心血管事件的发生。β-受体阻滞剂治疗的适当持续时间仍是未知数，但观察性数据表明，对于 LVEF 为 40% 的 ACS 患者来说，在 ACS 后 1-12 个月后，任何降低死亡率的益处都可能丧失。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

European Journal of Clinical Investigation 医学-医学：内科

CiteScore

9.50

自引率

3.60%

发文量

192

审稿时长

1 months

期刊介绍： EJCI considers any original contribution from the most sophisticated basic molecular sciences to applied clinical and translational research and evidence-based medicine across a broad range of subspecialties. The EJCI publishes reports of high-quality research that pertain to the genetic, molecular, cellular, or physiological basis of human biology and disease, as well as research that addresses prevalence, diagnosis, course, treatment, and prevention of disease. We are primarily interested in studies directly pertinent to humans, but submission of robust in vitro and animal work is also encouraged. Interdisciplinary work and research using innovative methods and combinations of laboratory, clinical, and epidemiological methodologies and techniques is of great interest to the journal. Several categories of manuscripts (for detailed description see below) are considered: editorials, original articles (also including randomized clinical trials, systematic reviews and meta-analyses), reviews (narrative reviews), opinion articles (including debates, perspectives and commentaries); and letters to the Editor.