Editorial comment
The dilemma of beta-blocker use after acute coronary syndrome: To support the dogma or to embrace the paradigm shift?
O dilema do uso de bloqueadores beta após uma síndroma coronária aguda: manter o dogma ou abraçar a mudança de paradigma?
Daniel Ferreira
Cardiovascular Centre, Hospital da Luz Lisboa, Lisbon, Portugal
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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "909" "paginaFinal" => "910" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Daniel Ferreira" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Daniel" "apellidos" => "Ferreira" "email" => array:1 [ 0 => "dferreira@hospitaldaluz.pt" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Cardiovascular Centre, Hospital da Luz Lisboa, Lisbon, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "O dilema do uso de bloqueadores beta após uma síndroma coronária aguda: manter o dogma ou abraçar a mudança de paradigma?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">The old evidence</span><p id="par0005" class="elsevierStylePara elsevierViewall">Since the last quarter of the 20th century, beta-blockers have been considered a cornerstone therapy after acute coronary syndrome (ACS), alongside reperfusion therapy, antiplatelet agents, statins and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Together, these therapies have led to striking improvements in the outcome of these syndromes, in terms of both mortality and morbidity.</p><p id="par0015" class="elsevierStylePara elsevierViewall">More recent advances in organizational models of response to ACS and in reperfusion therapy, with wider availability of percutaneous coronary intervention (PCI) replacing pharmacological reperfusion therapy, have led to further significant reductions in mortality and morbidity, particularly in terms of heart failure and mechanical complications following myocardial infarction (MI).</p><p id="par0020" class="elsevierStylePara elsevierViewall">With every new advance in this field, researchers should question old dogmas and reassess previous strategies, procedures and drug indications. Current guidelines should be seen as such, as current, and should be periodically revised. This is regularly done by the major cardiological societies, at the national and continental (and even international) level.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In the latest updates of the American and European guidelines on MI, beta-blocker use is still a class I or IIa indication for patients after both ST-elevation MI<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1,2</span></a> and non-ST-elevation ACS.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3,4</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">The new evidence</span><p id="par0030" class="elsevierStylePara elsevierViewall">However, several authors have questioned this indication, especially in patients without left ventricular dysfunction, in most cases on the basis of registries<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">5–8</span></a> and/or meta-analyses of real-world population-based studies.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">9–11</span></a> These authors all suggest that a paradigm shift is needed and that the guidelines’ indication for beta-blocker use after MI should be challenged.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>, another piece of evidence is published that keeps this discussion wide open. In their interesting article, Timóteo et al.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> present a single-center study that again supports the use of beta-blockers after ACS, as this strategy showed a significant reduction in all-cause mortality, irrespective of residual left ventricular function.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The potential limitations of the study being based on a single center were overcome by a robust statistical analysis with the use of propensity-score matching, a large number of patients, and an impressive 99.8% of successful one-year follow-up.</p><p id="par0045" class="elsevierStylePara elsevierViewall">One of the limitations acknowledged by the authors is the lack of information regarding the type and dose of the beta-blockers used, but the same limitation also applies to similar studies and meta-analyses.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">The dilemma</span><p id="par0050" class="elsevierStylePara elsevierViewall">So we are faced with a significant dilemma. Should we support the dogmatic approach and continue to prescribe beta-blockers for our post-ACS patients, based on indications in the current guidelines and on studies like that of Timóteo et al.?<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">12–15</span></a> Or should we follow Thomas Kuhn's view that science is based on paradigm shifts and challenge these indications, as advocated by the above more recent meta-analyses?<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">9–11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">I, for one, as a man of science, would like to have as much robust data as possible, which means that I would like to see contemporary randomized clinical trials (RCTs) that study the results of prescribing beta-blockers after ACS alongside the more recent strategies of care (including modern reperfusion therapies) recommended for these syndromes.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The question, of course, is whether the pharmaceutical industry would support RCTs that question the continued use of old and cheap drugs. This is a clear case for investigator-driven studies, supported by their institutions and/or medical societies, such as the recent article by Watanabe et al.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a> which published the results of the CAPITAL-RCT study, showing no benefit from the use of carvedilol in patients with ST-elevation MI treated with primary PCI. Similar studies are needed in order to clarify this important clinical question.</p><p id="par0065" class="elsevierStylePara elsevierViewall">To the quote attributed to W. Edwards Deming, “In God we trust; all others must bring data,” I would add: “… robust data”.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">Daniel Ferreira has received honoraria (advisory board member and/or invited speaker) from Astellas, Astra-Zeneca, Bayer, BMS/Pfizer, Boehringer-Ingelheim, Novartis, and Sanofi-Aventis.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "The old evidence" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "The new evidence" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "The dilemma" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P.T. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 3 | 11 |
| 2024 October | 42 | 26 | 68 |
| 2024 September | 38 | 26 | 64 |
| 2024 August | 33 | 27 | 60 |
| 2024 July | 35 | 25 | 60 |
| 2024 June | 28 | 27 | 55 |
| 2024 May | 27 | 30 | 57 |
| 2024 April | 37 | 24 | 61 |
| 2024 March | 26 | 26 | 52 |
| 2024 February | 21 | 26 | 47 |
| 2024 January | 22 | 23 | 45 |
| 2023 December | 20 | 28 | 48 |
| 2023 November | 21 | 22 | 43 |
| 2023 October | 17 | 13 | 30 |
| 2023 September | 20 | 26 | 46 |
| 2023 August | 17 | 11 | 28 |
| 2023 July | 16 | 8 | 24 |
| 2023 June | 19 | 10 | 29 |
| 2023 May | 38 | 26 | 64 |
| 2023 April | 31 | 5 | 36 |
| 2023 March | 33 | 18 | 51 |
| 2023 February | 25 | 13 | 38 |
| 2023 January | 20 | 18 | 38 |
| 2022 December | 47 | 34 | 81 |
| 2022 November | 43 | 22 | 65 |
| 2022 October | 40 | 20 | 60 |
| 2022 September | 33 | 34 | 67 |
| 2022 August | 23 | 28 | 51 |
| 2022 July | 24 | 39 | 63 |
| 2022 June | 33 | 19 | 52 |
| 2022 May | 65 | 25 | 90 |
| 2022 April | 23 | 27 | 50 |
| 2022 March | 23 | 38 | 61 |
| 2022 February | 30 | 32 | 62 |
| 2022 January | 21 | 26 | 47 |
| 2021 December | 24 | 35 | 59 |
| 2021 November | 21 | 24 | 45 |
| 2021 October | 42 | 37 | 79 |
| 2021 September | 30 | 17 | 47 |
| 2021 August | 50 | 30 | 80 |
| 2021 July | 56 | 22 | 78 |
| 2021 June | 36 | 24 | 60 |
| 2021 May | 70 | 43 | 113 |
| 2021 April | 90 | 54 | 144 |
| 2021 March | 46 | 12 | 58 |
| 2021 February | 37 | 16 | 53 |
| 2021 January | 22 | 13 | 35 |
| 2020 December | 20 | 11 | 31 |
| 2020 November | 18 | 17 | 35 |
| 2020 October | 13 | 9 | 22 |
| 2020 September | 23 | 13 | 36 |
| 2020 August | 9 | 5 | 14 |
| 2020 July | 31 | 12 | 43 |
| 2020 June | 11 | 10 | 21 |
| 2020 May | 14 | 8 | 22 |
| 2020 April | 12 | 7 | 19 |
| 2020 March | 18 | 7 | 25 |
| 2020 February | 33 | 28 | 61 |
| 2020 January | 11 | 5 | 16 |
| 2019 December | 20 | 9 | 29 |
| 2019 November | 14 | 7 | 21 |
| 2019 October | 13 | 4 | 17 |
| 2019 September | 17 | 7 | 24 |
| 2019 August | 22 | 11 | 33 |
| 2019 July | 28 | 10 | 38 |
| 2019 June | 26 | 22 | 48 |
| 2019 May | 26 | 12 | 38 |
| 2019 April | 18 | 15 | 33 |
| 2019 March | 15 | 14 | 29 |
| 2019 February | 16 | 10 | 26 |
| 2019 January | 9 | 5 | 14 |
| 2018 December | 10 | 14 | 24 |
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