Clinical Outcomes with β-Blockers for Myocardial Infarction: A Meta-analysis of Randomized Trials Sripal Bangalore, MD, MHA, Harikrishna Makani, MD,

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Presentation transcript:

Clinical Outcomes with β-Blockers for Myocardial Infarction: A Meta-analysis of Randomized Trials Sripal Bangalore, MD, MHA, Harikrishna Makani, MD, Martha Radford, MD, Kamia Thakur, MD, Bora Toklu, MD, Stuart D. Katz, MD, James J. DiNicolantonio, PharmD, P.J. Devereaux, MD, PhD, Karen P. Alexander, MD, Jorn Wetterslev, MD, PhD, Franz H. Messerli, MD The American Journal of Medicine Volume 127, Issue 10, Pages 939-953 (October 2014) DOI: 10.1016/j.amjmed.2014.05.032 Copyright © 2014 Elsevier Inc. Terms and Conditions

Figure 1 Study selection. The American Journal of Medicine 2014 127, 939-953DOI: (10.1016/j.amjmed.2014.05.032) Copyright © 2014 Elsevier Inc. Terms and Conditions

Figure 2 β-blockers vs controls for the outcome of all-cause mortality in acute myocardial infarction trials. Analysis stratified by reperfusion status. CI = confidence interval; COMMIT = Clopidogrel and Metoprolol in Myocardial Infarction Trial; EMIT = Esmolol Myocardial Ischemia Trial; ICSG = The International Collaborative Study Group; IRR = incident rate ratio; ISIS-1 = First International Study of Infarct Survival Collaborative Group; MEMO = Metoprolol-Morphine Study Group; METOCARD-CNIC = Effect of Metroprolol in Cardioprotection During an Acute Myocardial Infarction trial; MIAMI = Metoprolol in Acute Myocardial Infarction; MILIS = Multicenter Investigation for the Limitation of Infarct Size; RIMA = Rimodellamento Infarcto Miocardico Acuto Study; TIMI = Thrombolysis in Myocardial Infarction; UKCSG = UK Collaborative Study Group. The American Journal of Medicine 2014 127, 939-953DOI: (10.1016/j.amjmed.2014.05.032) Copyright © 2014 Elsevier Inc. Terms and Conditions

Figure 3 β-blockers vs controls for the outcome of myocardial infarction in acute myocardial infarction trials. Analysis stratified by reperfusion status. CI = confidence interval; COMMIT = Clopidogrel and Metoprolol in Myocardial Infarction Trial; EMIT = Esmolol Myocardial Ischemia Trial; ICSG = The International Collaborative Study Group; IRR = incident rate ratio; ISIS-1 = First International Study of Infarct Survival Collaborative Group; MEMO = Metoprolol-Morphine Study Group; METOCARD-CNIC = Effect of Metroprolol in Cardioprotection During an Acute Myocardial Infarction trial; MIAMI = Metoprolol in Acute Myocardial Infarction; MILIS = Multicenter Investigation for the Limitation of Infarct Size; RIMA = Rimodellamento Infarcto Miocardico Acuto Study; TIMI = Thrombolysis in Myocardial Infarction; UKCSG = UK Collaborative Study Group. The American Journal of Medicine 2014 127, 939-953DOI: (10.1016/j.amjmed.2014.05.032) Copyright © 2014 Elsevier Inc. Terms and Conditions

Figure 4 β-blockers vs controls for the outcome of angina pectoris in acute myocardial infarction trials. Analysis stratified by reperfusion status. CI = confidence interval; COMMIT = Clopidogrel and Metoprolol in Myocardial Infarction Trial; EMIT = Esmolol Myocardial Ischemia Trial; ICSG = The International Collaborative Study Group; IRR = incident rate ratio; ISIS-1 = First International Study of Infarct Survival Collaborative Group; MEMO = Metoprolol-Morphine Study Group; METOCARD-CNIC = Effect of Metroprolol in Cardioprotection During an Acute Myocardial Infarction trial; MIAMI = Metoprolol in Acute Myocardial Infarction; MILIS = Multicenter Investigation for the Limitation of Infarct Size; RIMA = Rimodellamento Infarcto Miocardico Acuto Study; TIMI = Thrombolysis in Myocardial Infarction; UKCSG = UK Collaborative Study Group. The American Journal of Medicine 2014 127, 939-953DOI: (10.1016/j.amjmed.2014.05.032) Copyright © 2014 Elsevier Inc. Terms and Conditions

Figure 5 β-blockers vs controls for the outcome of heart failure in acute myocardial infarction trials. Analysis stratified by reperfusion status. CI = confidence interval; COMMIT = Clopidogrel and Metoprolol in Myocardial Infarction Trial; EMIT = Esmolol Myocardial Ischemia Trial; ICSG = The International Collaborative Study Group; IRR = incident rate ratio; ISIS-1 = First International Study of Infarct Survival Collaborative Group; MEMO = Metoprolol-Morphine Study Group; METOCARD-CNIC = Effect of Metroprolol in Cardioprotection During an Acute Myocardial Infarction trial; MIAMI = Metoprolol in Acute Myocardial Infarction; MILIS = Multicenter Investigation for the Limitation of Infarct Size; RIMA = Rimodellamento Infarcto Miocardico Acuto Study; TIMI = Thrombolysis in Myocardial Infarction; UKCSG = UK Collaborative Study Group. The American Journal of Medicine 2014 127, 939-953DOI: (10.1016/j.amjmed.2014.05.032) Copyright © 2014 Elsevier Inc. Terms and Conditions

Figure 6 β-blockers vs controls for the outcome of cardiogenic shock in acute myocardial infarction trials. Analysis stratified by reperfusion status. CI = confidence interval; COMMIT = Clopidogrel and Metoprolol in Myocardial Infarction Trial; EMIT = Esmolol Myocardial Ischemia Trial; ICSG = The International Collaborative Study Group; IRR = incident rate ratio; ISIS-1 = First International Study of Infarct Survival Collaborative Group; MEMO = Metoprolol-Morphine Study Group; METOCARD-CNIC = Effect of Metroprolol in Cardioprotection During an Acute Myocardial Infarction trial; MIAMI = Metoprolol in Acute Myocardial Infarction; MILIS = Multicenter Investigation for the Limitation of Infarct Size; RIMA = Rimodellamento Infarcto Miocardico Acuto Study; TIMI = Thrombolysis in Myocardial Infarction; UKCSG = UK Collaborative Study Group. The American Journal of Medicine 2014 127, 939-953DOI: (10.1016/j.amjmed.2014.05.032) Copyright © 2014 Elsevier Inc. Terms and Conditions

Figure 7 β-blockers vs controls and drug discontinuation in acute myocardial infarction trials. Analysis stratified by reperfusion status. CI = confidence interval; COMMIT = Clopidogrel and Metoprolol in Myocardial Infarction Trial; EMIT = Esmolol Myocardial Ischemia Trial; ICSG = The International Collaborative Study Group; IRR = incident rate ratio; ISIS-1 = First International Study of Infarct Survival Collaborative Group; MEMO = Metoprolol-Morphine Study Group; METOCARD-CNIC = Effect of Metroprolol in Cardioprotection During an Acute Myocardial Infarction trial; MIAMI = Metoprolol in Acute Myocardial Infarction; MILIS = Multicenter Investigation for the Limitation of Infarct Size; RIMA = Rimodellamento Infarcto Miocardico Acuto Study; TIMI = Thrombolysis in Myocardial Infarction; UKCSG = UK Collaborative Study Group. The American Journal of Medicine 2014 127, 939-953DOI: (10.1016/j.amjmed.2014.05.032) Copyright © 2014 Elsevier Inc. Terms and Conditions

Figure 8 β-blockers vs controls for the outcome of all-cause mortality in postmyocardial infarction trials. Analysis stratified by reperfusion status. APSI = Acebutolol et Prévention Secondaire de l'Infarctus; BHAT = Beta-Blocker Heart Attack Trial; CI = confidence interval; CPRG = Coronary Prevention Research Group; EIS = European Infarction Study; IRR = incident rate ratio; JCBMI = The Japanese beta Blockers and Calcium Antagonists Myocardial Infarction; LIT = Lopressor Intervention Trial Research Group. The American Journal of Medicine 2014 127, 939-953DOI: (10.1016/j.amjmed.2014.05.032) Copyright © 2014 Elsevier Inc. Terms and Conditions

Figure 9 β-blockers vs controls for the outcome of myocardial infarction in post myocardial infarction trials. Analysis stratified by reperfusion status. APSI = Acebutolol et Prévention Secondaire de l'Infarctus; BHAT = Beta-Blocker Heart Attack Trial; CI = confidence interval; CPRG = Coronary Prevention Research Group; EIS = European Infarction Study; IRR = incident rate ratio; JCBMI = The Japanese beta Blockers and Calcium Antagonists Myocardial Infarction; LIT = Lopressor Intervention Trial Research Group. The American Journal of Medicine 2014 127, 939-953DOI: (10.1016/j.amjmed.2014.05.032) Copyright © 2014 Elsevier Inc. Terms and Conditions

Figure 10 β-blockers vs controls for the outcome of heart failure in post myocardial infarction trials. Analysis stratified by reperfusion status. APSI = Acebutolol et Prévention Secondaire de l'Infarctus; BHAT = Beta-Blocker Heart Attack Trial; CI = confidence interval; CPRG = Coronary Prevention Research Group; EIS = European Infarction Study; IRR = incident rate ratio; JCBMI = The Japanese beta Blockers and Calcium Antagonists Myocardial Infarction; LIT = Lopressor Intervention Trial Research Group. The American Journal of Medicine 2014 127, 939-953DOI: (10.1016/j.amjmed.2014.05.032) Copyright © 2014 Elsevier Inc. Terms and Conditions

Figure 11 β-blockers vs controls and drug discontinuation in postmyocardial infarction trials. Analysis stratified by reperfusion status. APSI = Acebutolol et Prévention Secondaire de l'Infarctus; BHAT = Beta-Blocker Heart Attack Trial; CI = confidence interval; CPRG = Coronary Prevention Research Group; EIS = European Infarction Study; IRR = incident rate ratio; JCBMI = The Japanese beta Blockers and Calcium Antagonists Myocardial Infarction; LIT = Lopressor Intervention Trial Research Group. The American Journal of Medicine 2014 127, 939-953DOI: (10.1016/j.amjmed.2014.05.032) Copyright © 2014 Elsevier Inc. Terms and Conditions

Figure 12 Trial Sequential Analysis using fixed-effect meta-analysis in the reperfusion era. The required information of 49,990 patients is based on an anticipated intervention effect of 10% relative risk reduction, a control event proportion of 7.36% (estimated from the cumulated comparator event proportion), absence of heterogeneity (diversity = 0%), and α = 0.05 and β = 0.10. The American Journal of Medicine 2014 127, 939-953DOI: (10.1016/j.amjmed.2014.05.032) Copyright © 2014 Elsevier Inc. Terms and Conditions

Figure 13 Meta-regression analysis of the relationship of percentage of patients with reperfusion therapy on the risk ratio of mortality with β-blockers. The American Journal of Medicine 2014 127, 939-953DOI: (10.1016/j.amjmed.2014.05.032) Copyright © 2014 Elsevier Inc. Terms and Conditions