Editorial comment
Beta-blocker therapy after myocardial infarction or acute coronary syndrome: What we don’t know
Terapêutica com β-bloqueantes após enfarte do miocárdio ou síndrome coronária aguda: o que não sabemos
José Ilídio Moreira
Serviço de Cardiologia, Centro Hospitalar de Trás-os-Montes e Alto Douro (Hospitais de Vila Real, Chaves e Lamego), Vila Real, Portugal
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(A) Endoscopic view from a right minithoracotomy, showing ruptured chordae of P2 segment; (B) Da Vinci robot; (C) surgical steps of chordal implantation with the Harpoon device (left anterior minithoracotomy in beating heart without extracorporeal circulation<a class="elsevierStyleCrossRef" href="#bib0805"><span class="elsevierStyleSup">72</span></a>).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Gonçalo F. Coutinho, Manuel J. Antunes" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Gonçalo F." "apellidos" => "Coutinho" ] 1 => array:2 [ "nombre" => "Manuel J." 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LVEF: left ventricular ejection fraction.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jesús Velásquez-Rodríguez, Vanesa Bruña, Lourdes Vicent, Felipe Díez-Delhoyo, María Jesús Valero-Masa, Iago Sousa-Casasnovas, Miriam Juárez, Carolina Devesa, Francisco Fernández-Avilés, Manuel Martínez-Sellés" "autores" => array:10 [ 0 => array:2 [ "nombre" => "Jesús" "apellidos" => "Velásquez-Rodríguez" ] 1 => array:2 [ "nombre" => "Vanesa" "apellidos" => "Bruña" ] 2 => array:2 [ "nombre" => "Lourdes" "apellidos" => "Vicent" ] 3 => array:2 [ "nombre" => "Felipe" "apellidos" => "Díez-Delhoyo" ] 4 => array:2 [ "nombre" => "María Jesús" "apellidos" => "Valero-Masa" ] 5 => array:2 [ "nombre" => "Iago" "apellidos" => "Sousa-Casasnovas" ] 6 => array:2 [ "nombre" => "Miriam" "apellidos" => "Juárez" ] 7 => array:2 [ "nombre" => "Carolina" "apellidos" => "Devesa" ] 8 => array:2 [ "nombre" => "Francisco" "apellidos" => "Fernández-Avilés" ] 9 => array:2 [ "nombre" => "Manuel" "apellidos" => "Martínez-Sellés" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S087025512100041X?idApp=UINPBA00004E" "url" => "/08702551/0000004000000004/v1_202103300712/S087025512100041X/v1_202103300712/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Beta-blocker therapy after myocardial infarction or acute coronary syndrome: What we don’t know" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "291" "paginaFinal" => "292" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "José Ilídio Moreira" "autores" => array:1 [ 0 => array:3 [ "nombre" => "José Ilídio" "apellidos" => "Moreira" "email" => array:1 [ 0 => "jimoreira2@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Centro Hospitalar de Trás-os-Montes e Alto Douro (Hospitais de Vila Real, Chaves e Lamego), Vila Real, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Terapêutica com β-bloqueantes após enfarte do miocárdio ou síndrome coronária aguda: o que não sabemos" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Despite significant advances in the management of acute coronary syndromes (ACS) over recent decades, there are still some gaps in evidence.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The importance of beta-blockers in the context of pharmacological treatment during and after an ACS is well recognized. The indications concerning patients with left ventricular (LV) systolic dysfunction and ejection fraction (EF) <40% are clear. Unless there is a contraindication or the patient is in overt heart failure, the European and American guidelines confer a class I recommendation for beta-blocker use after both ST- and non-ST-segment elevation ACS (NSTE-ACS).<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The data are not as conclusive in patients without LV dysfunction. Several registries, meta-analyses and population-based studies question this indication,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> especially in the setting of ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> In their paper published in the current issue of the <span class="elsevierStyleItalic">Journal</span>, Velásquez-Rodríguez et al. focus on this issue.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> Despite the limitations of their observational study, which are recognized by the authors, the results in patients with LV systolic dysfunction who tolerate beta-blocker therapy at hospital discharge are consistent. By contrast, for the LVEF >40% patient group, the results are inconclusive and raise questions.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Other observational studies in contemporary ACS populations suggest that the benefits of beta-blocker use after ACS are still significant in patients with preserved LV systolic function.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">These uncertainties are more understandable when we take a closer look at the guidelines. The European Society of Cardiology (ESC) guidelines confer a class IIa recommendation, level of evidence B, in patients without heart failure and preserved LVEF, for routine beta-blocker therapy in the acute, subacute and long-term phases after STEMI.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> Nevertheless, the ESC recognizes that the role of maintenance beta-blocker therapy for patients without heart failure and/or low LVEF has not been prospectively tested in reperfused STEMI patients.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The most recent ESC statement on the management of NSTE-ACS<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> attributed the same class of recommendation – IIa, level of evidence B – for the use of beta-blockers in patients with preserved LV function (class I in patients with ongoing ischemic symptoms). It is important to emphasize that, in these guidelines, the value of long-term beta-blocker therapy in patients with LVEF >40% is listed among the gaps in evidence regarding care and future research.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The American ACS guidelines<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">2,4</span></a> recommend beta-blocker therapy for all patients without contraindications, regardless of heart failure or LVEF, with class I indication. The only exception is the class IIa recommendation, level of evidence C, assigned for chronic long-term therapy in patients after NSTE-ACS and with normal EF.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Many other guidelines and scientific statements, addressing different clinical settings, can be integrated into the management of these patients.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The ESC guidelines for the management of chronic coronary syndromes<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> state that the need for and duration of beta-blocker therapy following myocardial infarction (MI) in the absence of LV systolic dysfunction are unknown, referring to this as a gap in the evidence.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The American Heart Association (AHA) and American College of Cardiology (ACC) guideline for secondary prevention<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> states, as a class I recommendation, that beta-blocker therapy should be continued for three years in all patients with normal LV function who have had MI or ACS. Additionally, it states that it is reasonable to continue beta-blockers beyond three years as chronic therapy in all patients with normal LVEF after an ACS, in this case with a class IIa recommendation, level of evidence B.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Another important issue has to do with the age of the population, since the incidence of ACS increases with age, and patients aged >75 years are known to be under-represented in most cardiovascular trials. Likewise, those with complex comorbidities, significant physical disabilities, cognitive impairment or frailty are excluded. A statement from the AHA, ACC and American Geriatrics Society on knowledge gaps in cardiovascular care of the older adult population<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> emphasizes that current guidelines are unable to provide evidence-based recommendations for the diagnosis and treatment of older patients who are typical of those encountered in routine clinical practice. Among numerous recommendations, it states that more studies are needed to assess the benefits, risks, intensity, and duration of pharmacological agents, including beta-blockers, in older patients with ACS, paying particular attention to multimorbidity and polypharmacy.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion, I believe there is insufficient evidence to support the systematic use of beta-blockers for ACS patients with preserved EF, especially when treated with modern reperfusion therapies. Certainly, most of them benefit from this medication, but not all. Randomized clinical trials within this group are needed that include a broad spectrum of patients who are representative of those seen in clinical practice.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Meanwhile, we should not forget that the selection of a medical regimen should be individualized to each patient on the basis of in-hospital findings, life expectancy, functional and cognitive status, preferences, goals, comorbidities, frailty, risk of adverse effects and drug tolerability or interactions.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "B. 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| 2024 Setembro | 59 | 24 | 83 |
| 2024 Agosto | 62 | 32 | 94 |
| 2024 Julho | 79 | 39 | 118 |
| 2024 Junho | 68 | 28 | 96 |
| 2024 Maio | 50 | 23 | 73 |
| 2024 Abril | 41 | 28 | 69 |
| 2024 Maro | 39 | 29 | 68 |
| 2024 Fevereiro | 48 | 34 | 82 |
| 2024 Janeiro | 39 | 29 | 68 |
| 2023 Dezembro | 37 | 27 | 64 |
| 2023 Novembro | 67 | 42 | 109 |
| 2023 Outubro | 45 | 19 | 64 |
| 2023 Setembro | 60 | 26 | 86 |
| 2023 Agosto | 46 | 21 | 67 |
| 2023 Julho | 41 | 9 | 50 |
| 2023 Junho | 33 | 19 | 52 |
| 2023 Maio | 54 | 34 | 88 |
| 2023 Abril | 32 | 5 | 37 |
| 2023 Maro | 52 | 19 | 71 |
| 2023 Fevereiro | 57 | 26 | 83 |
| 2023 Janeiro | 26 | 20 | 46 |
| 2022 Dezembro | 50 | 27 | 77 |
| 2022 Novembro | 61 | 47 | 108 |
| 2022 Outubro | 96 | 39 | 135 |
| 2022 Setembro | 77 | 48 | 125 |
| 2022 Agosto | 77 | 33 | 110 |
| 2022 Julho | 89 | 46 | 135 |
| 2022 Junho | 86 | 53 | 139 |
| 2022 Maio | 98 | 47 | 145 |
| 2022 Abril | 61 | 47 | 108 |
| 2022 Maro | 75 | 48 | 123 |
| 2022 Fevereiro | 110 | 52 | 162 |
| 2022 Janeiro | 89 | 37 | 126 |
| 2021 Dezembro | 63 | 41 | 104 |
| 2021 Novembro | 65 | 46 | 111 |
| 2021 Outubro | 74 | 66 | 140 |
| 2021 Setembro | 67 | 31 | 98 |
| 2021 Agosto | 66 | 49 | 115 |
| 2021 Julho | 72 | 37 | 109 |
| 2021 Junho | 55 | 35 | 90 |
| 2021 Maio | 70 | 75 | 145 |
| 2021 Abril | 316 | 210 | 526 |
| 2021 Maro | 42 | 24 | 66 |
| 2021 Fevereiro | 3 | 3 | 6 |
Mostrar tudo
