Anke Neumann1, Géric Maura2, Alain Weill1, François Alla1, Nicolas Danchin1. 1. Department of Studies in Public Health, French National Health Insurance (Caisse nationale de l'Assurance Maladie, Cnam), Paris, France (A.N., G.M., A.W., F.A.); and Department of Cardiology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, INSERM 970, Université Paris Descartes, France (N.D.). 2. Department of Studies in Public Health, French National Health Insurance (Caisse nationale de l'Assurance Maladie, Cnam), Paris, France (A.N., G.M., A.W., F.A.); and Department of Cardiology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, INSERM 970, Université Paris Descartes, France (N.D.). geric.maura@cnamts.fr.
Abstract
BACKGROUND: β-blockers have been among the first medications shown to improve outcomes after acute myocardial infarction (AMI). With the advent of reperfusion therapy and other secondary-prevention medications, their role has become uncertain, and large-scale experience after AMI in the contemporary era is lacking. In particular, the effect of stopping β-blockers in patients initially treated after AMI is unknown. METHODS AND RESULTS: Using the French healthcare databases, 73 450 patients (<80 years of age), admitted for AMI in 2007 to 2012, without acute coronary syndrome (ACS) in the previous 2 years and no evidence of heart failure, having received optimal treatment with myocardial revascularization and all recommended medications in the 4 months after index admission, and not having discontinued β-blockers before 1 year, were followed for 3.8 years on average. β-Blocker discontinuation was defined as 4 consecutive months without exposure. If β-blocker treatment was resumed later on, follow-up was stopped. Both the risk of the composite outcome of death or admission for ACS and the risk of all-cause mortality were assessed in relation with β-blocker discontinuation during follow-up. Adjusted hazard ratios were estimated using marginal structural models accounting for time-varying confounders affected by previous exposure. A similar analysis was performed with statins. Of 204 592 patient-years, 12 002 (5.9%) corresponded to discontinued β-blocker treatment. For β-blocker discontinuation, the adjusted hazard ratio for death or ACS was 1.17 (95% confidence interval, 1.01-1.35); for all-cause death, the adjusted hazard ratio was 1.13 (95% confidence interval, 0.94-1.36). In contrast, for statin discontinuation, the adjusted hazard ratios for death or ACS and for all-cause death were 2.31 (95% confidence interval, 2.01-2.65) and 2.57 (95% confidence interval, 2.19-3.02), respectively. CONCLUSIONS: In routine care of patients without heart failure, revascularized and optimally treated after AMI, discontinuation of β-blockers beyond 1 year after AMI was associated with an increased risk of death or readmission for ACS, while statistical significance was not reached for the association with all-cause mortality. A contemporary randomized clinical trial is needed to precise the role of β-blockers in the long-term treatment after AMI.
BACKGROUND: β-blockers have been among the first medications shown to improve outcomes after acute myocardial infarction (AMI). With the advent of reperfusion therapy and other secondary-prevention medications, their role has become uncertain, and large-scale experience after AMI in the contemporary era is lacking. In particular, the effect of stopping β-blockers in patients initially treated after AMI is unknown. METHODS AND RESULTS: Using the French healthcare databases, 73 450 patients (<80 years of age), admitted for AMI in 2007 to 2012, without acute coronary syndrome (ACS) in the previous 2 years and no evidence of heart failure, having received optimal treatment with myocardial revascularization and all recommended medications in the 4 months after index admission, and not having discontinued β-blockers before 1 year, were followed for 3.8 years on average. β-Blocker discontinuation was defined as 4 consecutive months without exposure. If β-blocker treatment was resumed later on, follow-up was stopped. Both the risk of the composite outcome of death or admission for ACS and the risk of all-cause mortality were assessed in relation with β-blocker discontinuation during follow-up. Adjusted hazard ratios were estimated using marginal structural models accounting for time-varying confounders affected by previous exposure. A similar analysis was performed with statins. Of 204 592 patient-years, 12 002 (5.9%) corresponded to discontinued β-blocker treatment. For β-blocker discontinuation, the adjusted hazard ratio for death or ACS was 1.17 (95% confidence interval, 1.01-1.35); for all-cause death, the adjusted hazard ratio was 1.13 (95% confidence interval, 0.94-1.36). In contrast, for statin discontinuation, the adjusted hazard ratios for death or ACS and for all-cause death were 2.31 (95% confidence interval, 2.01-2.65) and 2.57 (95% confidence interval, 2.19-3.02), respectively. CONCLUSIONS: In routine care of patients without heart failure, revascularized and optimally treated after AMI, discontinuation of β-blockers beyond 1 year after AMI was associated with an increased risk of death or readmission for ACS, while statistical significance was not reached for the association with all-cause mortality. A contemporary randomized clinical trial is needed to precise the role of β-blockers in the long-term treatment after AMI.
Authors: Emmanuel Sorbets; Philippe Gabriel Steg; Robin Young; Nicolas Danchin; Nicola Greenlaw; Ian Ford; Michal Tendera; Roberto Ferrari; Bela Merkely; Alexander Parkhomenko; Christopher Reid; Jean-Claude Tardif; Kim M Fox Journal: Eur Heart J Date: 2019-05-07 Impact factor: 29.983