Beta-Blockers Post MI

Study investigators presented findings from the REBOOT-CNIC and BETAMI-DANBLOCK trials, as well as a larger meta-analysis of REBOOT, BETAMI, DANBLOCK and CAPITAL-RCT – all of which involved beta-blocker therapy following MI.

"Over the last 18 months, major trials, altogether enrolling more than 20,000 patients with an LVEF >40%, considered at low cardiovascular risk and without an indication for a beta-blocker, have assessed the effect of withholding beta-blockers, either immediately after an MI or with some delay, on the rate of major cardiovascular events over the subsequent two to four years," says John G.F. Cleland, MD, FACC, in an ACC.org perspective.

According to Cleland, none of the trials showed a significant difference in all-cause or cardiovascular mortality, although the BETAMI and DANBLOCK trials (which had been prospectively combined) reported there were fewer nonfatal MIs amongst those randomised to a beta-blocker.

"Overall, either giving or withholding a beta-blocker was similarly safe with a low (about 1%) all-cause mortality at one year," he says. "There was little evidence of heterogeneity amongst subgroups, although patients with an LVEF of 41-49% had a worse prognosis and appeared to benefit more from beta-blockers. Consequently, for those with an LVEF ≥50% the results might have favored withdrawing beta-blockers, especially amongst older patients with higher LVEF values, many of whom were women."

Cleland says the results of these trials should be interpreted and implemented with caution. "In clinical practice, the one-year mortality for those hospitalized with an MI is about 10% – tenfold higher than in these trials," he warns. "Indeed, since there is a high risk of events in the immediate aftermath of an MI and because a predischarge assessment of LVEF may not correlate well with LVEF measured some weeks later, it might be wise to initiate beta-blockers and other treatments routinely, reevaluate the patients six to 12 weeks later and withdraw unnecessary treatment at that time, which might include beta-blockers, RAS inhibitors and even antiplatelet agents."

Read the results of the individual trials.

Promising Models For Global Heart Health

New research on the use of reconditioned pacemakers in low- and middle-income countries and a home-based model of hypertension care in South Africa signal promising advancements for global heart health.

The MHYH trial conducted in Kenya, Mexico, Mozambique, Nigeria, Paraguay, Sierra Leone and Venezuela found procedure-related infection rates were noninferior between reconditioned pacemakers and new pacemakers, with no malfunctions.

"The work of Project My Heart Your Heart serves as a blueprint that can be replicated by other organizations to enable wider pacemaker reuse," said Thomas C. Crawford, MD, FACC. "We would also like to expand into reconditioned [ICD] devices, which are even more expensive and out of reach for many patients across the world."

The IMPACT-BP trial, simultaneously published in NEJM, showed that more patients randomized to home-based care and enhanced home-based care achieved hypertension control at six months than those receiving standard clinic-care (77%, 83% and 58% respectively).

"Achieving hypertension control in >80% of people in a predominantly Black African community ... is a clear example that equitable health care access can be achieved in disadvantaged communities," said Professor Nombulelo Magula. "Similar models of care that address structural barriers could be considered to improve hypertension control in other remote and resource-limited settings."