Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction - METOCARD-CNIC

Mar 30, 2014
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Author/Summarized by Author:
Anthony A. Bavry, MD,MPH,FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Trial Sponsor:
Centro Nacional de Investigaciones Cardiovasculares Carlos III
Date Presented:
01/01/2014
Date Updated:
03/30/2014
Original Posted Date:
03/30/2014
References

Description:

The goal of the trial was to evaluate treatment with early intravenous beta-blocker therapy compared with control among patients undergoing primary percutaneous coronary intervention (PCI).

Hypothesis:

Early intravenous beta-blocker therapy will reduce infarct size.

Study Design

  • Randomized
  • Parallel
  • Stratified

Patient Populations:

  • Patients ≥18 years of age with anterior STEMI

    Number of enrollees: 270
    Duration of follow-up: 7 days and 6 months 
    Mean patient age: 59 years
    Percentage female: 14%
    Mean ejection fraction: 46%

Exclusions:

  • Killip class III or IV
  • Systolic blood pressure <120 mm Hg
  • Heart rate <60 bpm
  • PR interval >240 ms
  • Active treatment with a beta-blocker

Primary Endpoints:

  • Infarct size at 5-7 days

Drug/Procedures Used:

Spanish patients with anterior ST-segment elevation myocardial infarction (STEMI) were randomized to intravenous metoprolol 5 mg, up to 3 doses (n = 131) versus control (n = 139). All patients received oral metoprolol within 24 hours.

Principal Findings:

Overall, 270 patients were randomized. The mean age was 59 years, 86% were men, mean body mass index was 28 kg/m2, 23% had diabetes, mean systolic blood pressure at recruitment was 143 mm Hg, and 82% received thrombus aspiration.

At least one dose of metoprolol was received in 99% of patients, two doses in 82%, and three doses in 67%.

Infarct size at 5-7 days was 25.6 g in the intravenous beta-blocker group versus 32.0 g in the control group (adjusted p = 0.012). This benefit was observed among patients with an occluded infarct artery prior to intervention, but not among those with an already reperfused infarct artery.

Left ventricular ejection fraction was 46.1% versus 43.4% (adjusted p = 0.045), respectively.

Major adverse cardiac events at 24 hours were 7.1% versus 12.3% (p = 0.21), respectively.

At 6 months, the mean left ventricular ejection fraction was 49% in the metoprolol group versus 45% in the control group (p = 0.025). Fewer participants in the metoprolol group had an indication for a defibrillator (p = 0.012). At 2 years, the composite of death, heart failure admission, re-infarction, and malignant arrhythmia was 10.8% in the metoprolol group versus 18.3% in the control group (p = 0.065).

Interpretation:

Among patients with anterior STEMI undergoing primary PCI, the use of early intravenous beta-blocker was associated with a smaller infarct size at 5-7 days compared with control. This resulted in improved left ventricular ejection fraction at 6 months. Although the trial was not powered for clinical endpoints, there was a favorable trend toward reduced adverse cardiovascular events in the metoprolol group.

In comparison, the COMMIT trial (>40,000 patients) documented a reduction in reinfarction and ventricular fibrillation at a cost of excess cardiogenic shock with intravenous metoprolol. The current study is limited by small size and a nonplacebo control group.

References:

Ibanez B, Macaya C, Sánchez-Brunete V, et al. Effect of Early Metoprolol on Infarct Size in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention: The Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction (METOCARD-CNIC) Trial. Circulation 2013;128:1495-503.

Pizarro G, Fernández-Friera L, Fuster V, et al. Long Term Benefit of Early Pre-reperfusion Metoprolol Administration in Patients With Acute Myocardial Infarction: Results From the METOCARD-CNIC Trial. J Am Coll Cardiol 2014;Mar 30:[Epub ahead of print].

Presented by Dr. Borja Ibanez at the American College of Cardiology Annual Scientific Session, Washington, DC, March 30, 2014.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Implantable Devices, SCD/Ventricular Arrhythmias, Acute Heart Failure

Keywords: Defibrillators, Follow-Up Studies, Ventricular Fibrillation, Blood Pressure, Percutaneous Coronary Intervention, Shock, Cardiogenic, Body Mass Index, Thrombosis, Heart Failure, Stroke Volume, Metoprolol, Diabetes Mellitus, ACC Annual Scientific Session


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