Beta-blocker therapy reduces mortality in patients with coronary artery disease treated with percutaneous revascularization: a meta-analysis of adjusted results

The clinical value of β-blockers in patients with stable angina

Stable angina, one manifestation of chronic coronary syndrome (CCS), is characterised by intermittent episodes of insufficient blood supply to the myocardium, provoking symptoms of myocardial ischaemia, particularly chest pain. These attacks usually occur during exercise or stress. Anti-ischaemic drugs are the mainstay of pharmacologic management of CCS with symptoms of angina. β-blockers reduce heart rate and myocardial contractility, thus reducing myocardial oxygen consumption. These drugs have been shown to ameliorate the frequency of anginal attacks and to improve exercise capacity in these patients. Current management guidelines include β-blockers as a first-line management option for most patients with CCS and symptoms of myocardial ischaemia, alongside dihydropyridine calcium channel blockers (CCB). The presence of comorbid angina and heart failure is a strong indication for starting with a β-blocker. β-blockers are also useful in the management of angina symptoms accompanied by a high heart rate, hypertension (with or without a renin-angiotensin-aldosterone-system [RAS] blocker or CCB), or microvascular angina (with a RAS blocker and a statin). A β-blocker is not suitable for a patient with low heart rate (<50 bpm), although use of a β-blocker may be supported by a pacemaker if the β-blocker is strongly indicated) and should be used at a low dose only in patients with low blood pressure.

Effect of beta-blocker therapy on the response to mavacamten in patients with symptomatic obstructive hypertrophic cardiomyopathy

AIMS

In the EXPLORER-HCM trial, mavacamten improved exercise capacity and symptoms in patients with obstructive hypertrophic cardiomyopathy (oHCM). Mavacamten effects on the primary endpoint, a composite of peak oxygen consumption (VO₂ ) and New York Heart Association (NYHA) class, were greater in patients not receiving background beta-blockers than in those receiving beta-blockers. We sought to determine if the effect of background treatment was consistent across other clinically meaningful parameters.

METHODS AND RESULTS

Subgroup analyses by beta-blocker use were performed in patients with oHCM from the EXPLORER-HCM and mavacamten long-term extension (MAVA-LTE) studies. In EXPLORER-HCM, 189 patients (75.3%) were receiving beta-blockers, and 62 (24.7%) were receiving non-dihydropyridine calcium channel blockers or no background HCM medication; 170 patients (90.4%) receiving beta-blockers had chronotropic incompetence. Improvements in peak VO₂ at week 30 with mavacamten versus placebo were lower with beta-blockers (mean difference [95% confidence interval (CI)]: 1.04 [0.12, 1.95] ml/kg/min) than without beta-blockers (mean difference [95% CI]: 2.69 [1.29, 4.09] ml/kg/min); improvements in non-heart rate-dependent parameters (V_E /VCO₂ slope) appeared unaffected by beta-blockers. Improvements in functional capacity parameters at week 30 with mavacamten versus placebo were independent of beta-blockade for post-exercise left ventricular outflow tract gradient (mean difference [95% CI]: -37.9 [-48.0, -27.9] mmHg with beta-blockers; -33.5 [-53.6, -13.3] mmHg without beta-blockers), proportion of patients with reduction of ≥1 NYHA class, Kansas City Cardiomyopathy Questionnaire clinical summary scores and N-terminal pro-B-type natriuretic peptide. Mavacamten benefits were reproduced and maintained in MAVA-LTE regardless of beta-blockade.

CONCLUSION

Mavacamten improved measures of functional capacity, left ventricular outflow tract obstruction, symptom burden and biomarkers in patients with HCM regardless of beta-blocker use. Beta-blocker use was often associated with chronotropic incompetence, affecting peak VO₂ and other heart rate-dependent measures, but had minimal impact on heart rate-independent measures.

Long-Term Beta-Blocker Therapy After Myocardial Infarction Without Heart Failure in the Reperfusion Era-Systemic Review and Meta-analysis

ABSTRACT

Beta-blockers are recommended as a standard treatment for patients who experience a myocardial infarction (MI). However, the evidence supporting this recommendation is based on the prereperfusion era data. This review aims to evaluate the effectiveness of long-term (≥1 year) beta-blocker therapy in post-MI patients without clinical heart failure (HF) in the reperfusion era. We included observational cohort studies, which compared at least 1 year use of beta-blockers to no beta-blockers in patients with an acute MI, but without HF. The clinical endpoint considered was all-cause mortality, except for cardiovascular death in one study. Five cohort studies and 217,532 patients were included. One study demonstrated a reduction in all-cause mortality with beta-blockers, whereas, in 4 studies, there was no difference in the death rate. The pooled estimate by random effect showed that beta-blocker treatment does not reduce mortality (odds ratio 0.800, 95% confidence interval 0.559-1.145) with high heterogeneity (I2 = 94%). This meta-analysis shows that the use of oral beta-blockers for 1 year or more does not reduce the mortality of MI patients without HF. Large randomized trials need to evaluate beta-blocker discontinuation after an acute MI.

Cardiovascular therapeutics: A new potential for anxiety treatment?

Besides the well‐recognized risk factors, novel conditions increasing cardiovascular morbidity and mortality are emerging. Undesirable emotions and behavior such as anxiety and depression, appear to participate in worsening cardiovascular pathologies. On the other hand, deteriorating conditions of the heart and vasculature result in disturbed mental and emotional health. The pathophysiological background of this bidirectional interplay could reside in an inappropriate activation of vegetative neurohormonal and other humoral systems in both cardiovascular and psychological disturbances. This results in circulus vitiosus potentiating mental and circulatory disorders. Thus, it appears to be of utmost importance to examine the alteration of emotions, cognition, and behavior in cardiovascular patients. In terms of this consideration, recognizing the potential of principal cardiovascular drugs to interact with the mental state in patients with heart or vasculature disturbances is unavoidable, to optimize their therapeutic benefit. In general, beta‐blockers, central sympatholytics, ACE inhibitors, ARBs, aldosterone receptor blockers, sacubitril/valsartan, and fibrates are considered to exert anxiolytic effect in animal experiments and clinical settings. Statins and some beta‐blockers appear to have an equivocal impact on mood and anxiety and ivabradine expressed neutral psychological impact. It seems reasonable to suppose that the knowledge of a patient's mood, cognition, and behavior, along with applying careful consideration of the choice of the particular cardiovascular drug and respecting its potential psychological benefit or harm might improve the individualized approach to the treatment of cardiovascular disorders.

Meta-Analysis of the Usefulness of Beta-Blockers to Reduce the Risk of Major Adverse Cardiovascular Events in Patients With Stable Coronary Artery Disease Without Prior Myocardial Infarction or Left Ventricular Dysfunction

Beta-blockers (BBs) are the core of coronary artery disease (CAD) pharmacotherapy and demonstrated a well-established benefit in the treatment of acute myocardial infarction (MI). However, the prophylactic role of BBs to affect adverse outcomes in patients with stable CAD, especially among those without a pervious history of MI or left ventricular dysfunction, is not yet addressed. We aimed to determine the effects of beta-blockers on major adverse cardiovascular events (MACE) in patients with stable CAD without prior MI or left ventricular dysfunction. We searched PubMed, EMBASE, Web of Science, Scopus, Google Scholar, and Cochrane Controlled Trials Register for studies published from inception to March 31, 2021. Two researchers independently reviewed the database searches and selected eligible studies. A third reviewer was consulted whenever necessary. A total of 6 studies were included in the final analysis. BBs therapy did not reduce the risk of a MACE (HR, 1.05; 95% CI, 0.91 to 1.20), MI (HR, 1.13; 95% CI, 0.95 to 1.34), and cardiovascular death (HR, 0.95; 95% CI, 0.79 to 1.14). No statistically significant effect was observed between the participants on beta-blocker and control groups. In conclusion, our meta-analysis did not show the benefit of BBs in reducing MACE among patients with stable CAD without previous history of MI or left ventricular dysfunction.

β-Blockade for Patients with Hypertension, Ischemic Heart Disease or Heart Failure: Where are We Now?

β-blockers are a heterogeneous class of drugs, with varying selectivity/specificity for β1 vs β2 receptors, intrinsic sympathomimetic activity (ISA), and vasodilatory properties (through β2 stimulation, α receptor blockade or nitric oxide release). These drugs are indicated for the management of arterial hypertension, heart failure or ischemic heart disease (IHD; eg angina pectoris or prior myocardial infarction). Most of the benefit of β-blockade in these conditions arises from blockade of the β1 receptor, and, in practice, the addition of ISA appears to reduce the potential for improved clinical outcomes in people with heart failure or IHD. Aspects of the benefit/risk balance of β-blockers remain controversial, and recent meta-analyses have shed new light on this issue. We have reviewed the current place of cardioselective β-blockade in hypertension, IHD and heart failure, with special reference to the therapeutic profile of a highly selective β1-adrenoceptor blocker, bisoprolol.

Association between β-blocker dose and cardiovascular outcomes after myocardial infarction: insights from the SWEDEHEART registry

AIMS

Dose-dependent effects of β-blockers on survival and cardiovascular outcomes after myocardial infarction (MI) are not well understood. We investigated the long-term risk of cardiovascular events in patients with different doses of β-blockers after MI.

METHODS AND RESULTS

This was a nationwide observational study linking morbidity, mortality, socioeconomic, and medication data from Swedish national registries. Between 2006 and 2015, 97 575 unique patients with first-time MI were included. In total, 33 126 (33.9%) patients were discharged with ≥50% of the target β-blocker dose and 64 449 (66.1%) patients with <50% of the target β-blocker dose used in previous randomized trials. The primary composite endpoint was re-infarction or all-cause death within 1 year from discharge. Multivariable adjusted 1-year follow-up estimates using mixed effects Cox regression [HR (95% CI)] showed that patients treated with ≥50% of the target dose had a similar risk of the composite endpoint [1.03 (0.99-1.08)] and a somewhat higher risk when stroke, atrial fibrillation, or heart failure hospitalization were added to the composite endpoint [1.08 (1.04-1.12)], compared with patients on <50% of the target β-blocker dose. Results remained similar up to 5 years of follow-up and consistent across relevant patient subgroups, including patients who developed heart failure during the index hospitalization.

CONCLUSIONS

In contrast to doses of β-blockers used in previous trials, ≥50% of the target β-blocker dose was not associated with superior cardiovascular outcomes up to 5 years as compared with <50% of the target dose. Contemporary randomized clinical trials are needed to clarify the optimal dose of β-blockers after MI.

Effects of a Secondary Prevention Combination Therapy with beta-Blocker and Statin on Major Adverse Cardiovascular Events in Acute Coronary Syndrome Patients

BACKGROUND The efficacy of a beta-blocker or statin alone versus combination therapy is uncertain. We compared the effects of a combination of beta-blocker and statin with those of one-drug therapies with regard to the occurrence of a major adverse cardiovascular event (MACE) in patients with acute coronary syndrome (ACS). MATERIAL AND METHODS From 2011 to 2013, 636 ACS patients were included. Based on their risk category, enrolled subjects were assigned into 4 groups receiving consistent beta-blocker and/or statin treatment: no therapy group (n=139), with never use or inconsistent use beta-blocker and statin; beta-blocker monotherapy group (n=71); statin monotherapy group (n=149); and cotherapy group (n=277). RESULTS Men composed 66.8% of the cohort, which had a mean age of 60.42±9.83 years. Compared with the no therapy group, the statin monotherapy group and cotherapy group had a lower risk of MACE (statin monotherapy group: adjusted hazard ratio [HR] 0.35, 95% confidence interval [CI] 0.20-0.60, P<.001; cotherapy group: adjusted HR 0.16, 95% CI 0.09-0.28, P<.001). Subgroup analysis indicated that, compared with beta-blocker monotherapy and statin monotherapy, cotherapy significantly reduced the risks of MACE occurrences in ACS patients (beta-blocker monotherapy group: adjusted HR 0.28, 95% CI 0.13-0.59, P=.001; statin monotherapy group: adjusted HR 0.54, 95% CI 0.29-0.98, P=.044). CONCLUSIONS Beta-blocker and statin combination therapy lowered the risk of developing MACE in ACS patients.

Poor adherence to beta-blockers is associated with increased long-term mortality even beyond the first year after an acute coronary syndrome event

Background: Acute coronary syndrome (ACS) patients are widely treated with long-term beta-blocker therapy after cardiac event. Especially for low-risk patients, the benefits of beta-blockers on survival and the optimal therapy duration remain unclear. We investigated the effect of adherence to beta-blockers on long-term survival of ACS patients.Methods and results: A total of 1855 consecutive ACS patients who underwent angiography and survived 30 days after were followed for a median of 8.6 years. During follow-up, 30.1% (n = 558) of patients died. Adherence was assessed as yearly periods covered by medication purchases and investigated as a dynamic time-dependent variable in Cox proportional hazards models. In a univariable model, non-adherence to beta-blockers was associated with higher all-cause mortality (Hazard ratio [HR] 2.99, 95% confidence interval [CI] 2.50-3.57; p < .001). Results were similar in multivariable models on both overall survival (HR 1.84, 95% CI 1.51-2.24; p < .001) and on 1-year landmark survival (HR 1.74, 95% CI 1.41-2.14; p < .001). In subgroup analyses, the increase in all-cause mortality was consistent among low-risk patients (HR 1.60, 95% CI 1.16-2.21; p = .004).Conclusion: Poor adherence to beta-blockers is associated with increased long-term mortality among ACS patients. Even low-risk patients seem to benefit from long-term beta-blocker therapy.Key messagesAdherence to secondary prevention medications diminishes drastically over the years after an ACS event.Non-adherence to β-blockers is associated with increased long-term mortality of ACS patients, and the effect on survival extends beyond the first year after an ACS event.Our follow-up was exceptionally lengthy with median follow-up period of 8.6 years.

Female sex impact on culprit plaque at optical coherence tomography analysis in the setting of acute coronary syndrome in OCT-FORMIDABLE registry

Aim: To evaluate sex difference in culprit plaque features at optical coherence tomography (OCT) and major adverse cardiovascular events at follow-up. Patients and methods: We analyse data from the OCT-FORMIDABLE (OCT-Features Of moRphology, coMposItion anD instABility of culprit and pLaquE in acute coronary syndrome [ACS] patients) registry. A total of 285 patients (20%, 58 females) were included. Results: Females with ST segment elevation myocardial infarction showed a longer ruptured area of the plaque (8.6 ± 7.6 vs 4.6 ± 5.4; p = 0.003) and a major necrotic core macrophage infiltration (43 vs 17%; p = 0.017). Females with non-ST segment elevation-ACS had less lipidic plaques (62 vs 80%; p = 0.04). No between-group sex differences in major adverse cardiovascular events emerged at follow-up (5 vs 9%; p = 0.88 in ST segment elevation myocardial infarction group and 19 vs 15%; p = 0.6 in non-ST segment elevation-ACS group). At multivariate analysis, female sex was not a major risk of plaque rupture (hazard ratio [HR]: 1.59, CI: 0.44–5.67; p = 0.48). Conclusion: Female sex seems to have no significant impact.

ClincalTrial. gov registration number: NCT02486861.

A Critical Review of Nebivolol and its Fixed-Dose Combinations in the Treatment of Hypertension

β-Adrenergic receptor blockers (β-blockers) are well-known useful and cost-effective drugs for managing hypertensive patients with coronary heart disease, stroke, and heart failure. However, it is often difficult to use β-blockers for patients with asthma or chronic obstructive pulmonary disease (COPD). Moreover, most β-blockers negatively influence glucose or lipid metabolism. Nebivolol is a third-generation lipophilic β-1 receptor-selective blocker with nitric oxide-mediated vasodilatory effects, metabolically neutral and usually well tolerated by patients with asthma or COPD. Nebivolol has significant effects of reduction in central blood pressure and improvements in endothelial dysfunction and arterial stiffness. To summarize the merits and demerits of nebivolol in different clinical situations, we conducted a review using the word 'nebivolol' on Pubmed and Embase, limiting the search to hypertension, clinical trials, and meta-analyses. This review summarizes the clinical studies on nebivolol itself and on the combination of nebivolol with other antihypertensive drugs, such as hydrochlorothiazide, angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, and amlodipine. Most studies showed the safety and well-tolerated profile of nebivolol and the combination of nebivolol with other antihypertensive drugs, which suggests that new fixed combinations of nebivolol with other antihypertensive drugs would be useful for patients who are unable to tolerate traditional β-blockers.