Letter to the Editor
Beta-blockers in acute coronary syndrome patients: The concept of ‘gradient of benefit’
Betabloqueadores no doente pós SCA: o conceito de gradiente de benefício
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"identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "João" "apellidos" => "Morais" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Hospital Pedro Hispano – ULS Matosinhos, Matosinhos, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centro Hospitalar de Leiria, Leiria, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Betabloqueadores no doente pós SCA: o conceito de gradiente de benefício" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 971 "Ancho" => 2167 "Tamanyo" => 180474 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Gradient of benefit for post-acute coronary syndrome patients. ACEi: angiotensin converting enzyme inhibitors; ACS: acute coronary syndrome; ARB: angiotensin receptor blockers; EF: ejection fraction; IH: in-hospital.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with interest the article by Velásquez-Rodríguez et al. published in the April 2021 issue of the <span class="elsevierStyleItalic">Journal</span>,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> which analyzes the impact of beta-blocker (BB) therapy in post-acute coronary syndrome (ACS) patients. In this important study, the population consisted of ST-elevation myocardial infarction (STEMI) patients divided into two groups according to left ventricular ejection fraction (LVEF): ≤40% vs. >40%. The impact of BB therapy in the ≤40% population is well known, and current guideline-directed medical therapy (GDMT) includes it as the first-line treatment to reduce heart rate.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> The real challenge is to understand the impact of BB therapy in currently treated post-ACS patients with LVEF >40%, since the main studies were performed in the pre-revascularisation era and the role of BB therapy in patients treated according to contemporary practice has been questioned.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> Our team has previously published a study investigating the therapeutic impact on in-hospital mortality in currently treated post-ACS patients (n=9429) stratified according to LVEF, adding a third group – patients with mid-range LVEF, between 40 and 50% (n=1926, 20%).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> Regarding the group with low LVEF, our results support the conclusions achieved by Velásquez-Rodríguez et al., with BB therapy having an impact in reducing in-hospital mortality. However, in the intermediate LVEF group, BB therapy also had an impact on in-hospital mortality. In patients with LVEF >50% there was no benefit from BB therapy (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> Similar findings were also seen in the Japanese CHART-2 study.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">In the study by Velásquez-Rodríguez et al., application of other forms of GDMT was lower than expected in the no-BB group (69.3% were on angiotensin-converting enzyme inhibitors). However, in our study, all GDMTs were used very frequently, and although other forms of ACS were included, coronary angiography was performed in >90% of the overall population.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> Only 6.2% of the population analyzed by Velásquez-Rodríguez et al. had atrial fibrillation, while in our study atrial fibrillation was diagnosed in less than 10% of the overall population, and thus its deleterious effects on BB efficacy may not have had a significant impact in either study.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> Neither study analyzed BB dosages, but a previous study by Ibrahim et al. assessed dosing and concluded that a higher dosage was only modestly beneficial in improving prognosis.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> A previous individual patient data meta-analysis by Cleland et al. including 11 trials also reinforced our conclusions, showing that BB therapy improved LVEF for patients in sinus rhythm and with LVEF <40%, and that for patients in the 40-50% range it appeared more likely to help than to harm.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In conclusion, it seems that as LVEF begins to fall, the margin for therapeutic benefit increases (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). The ideal cut-off for each GDMT is difficult to attain, but according to both these recent results, BB therapy may in fact start to be beneficial sooner than other GDMTs,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> at least for patients in sinus rhythm. This is a burning question that should be answered through future randomized controlled trials such as the ongoing REBOOT trial (ClinicalTrials.gov identifier: NCT03596385).</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors have 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 "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 971 "Ancho" => 2167 "Tamanyo" => 180474 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Gradient of benefit for post-acute coronary syndrome patients. ACEi: angiotensin converting enzyme inhibitors; ACS: acute coronary syndrome; ARB: angiotensin receptor blockers; EF: ejection fraction; IH: in-hospital.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Influence of left ventricular systolic function on the long-term benefit of beta-blockers after ST-segment elevation myocardial infarction" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J. Velásquez-Rodríguez" 1 => "V. Bruña" 2 => "L. Vicent" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.repc.2020.07.017" "Revista" => array:6 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2021" "volumen" => "40" "paginaInicial" => "285" "paginaFinal" => "290" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33642167" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0050" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P. Ponikowski" 1 => "A.A. Voors" 2 => "S.D. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 6 | 5 | 11 |
| 2024 Outubro | 43 | 38 | 81 |
| 2024 Setembro | 38 | 20 | 58 |
| 2024 Agosto | 37 | 27 | 64 |
| 2024 Julho | 28 | 34 | 62 |
| 2024 Junho | 38 | 30 | 68 |
| 2024 Maio | 28 | 14 | 42 |
| 2024 Abril | 28 | 37 | 65 |
| 2024 Maro | 39 | 18 | 57 |
| 2024 Fevereiro | 37 | 27 | 64 |
| 2024 Janeiro | 23 | 24 | 47 |
| 2023 Dezembro | 24 | 22 | 46 |
| 2023 Novembro | 31 | 31 | 62 |
| 2023 Outubro | 20 | 14 | 34 |
| 2023 Setembro | 35 | 20 | 55 |
| 2023 Agosto | 13 | 16 | 29 |
| 2023 Julho | 26 | 9 | 35 |
| 2023 Junho | 35 | 13 | 48 |
| 2023 Maio | 26 | 20 | 46 |
| 2023 Abril | 20 | 3 | 23 |
| 2023 Maro | 39 | 26 | 65 |
| 2023 Fevereiro | 20 | 22 | 42 |
| 2023 Janeiro | 16 | 14 | 30 |
| 2022 Dezembro | 38 | 39 | 77 |
| 2022 Novembro | 33 | 27 | 60 |
| 2022 Outubro | 42 | 27 | 69 |
| 2022 Setembro | 24 | 43 | 67 |
| 2022 Agosto | 19 | 34 | 53 |
| 2022 Julho | 37 | 42 | 79 |
| 2022 Junho | 35 | 36 | 71 |
| 2022 Maio | 18 | 23 | 41 |
| 2022 Abril | 37 | 30 | 67 |
| 2022 Maro | 36 | 43 | 79 |
| 2022 Fevereiro | 22 | 30 | 52 |
| 2022 Janeiro | 23 | 31 | 54 |
| 2021 Dezembro | 30 | 32 | 62 |
| 2021 Novembro | 37 | 40 | 77 |
| 2021 Outubro | 202 | 92 | 294 |
| 2021 Setembro | 39 | 48 | 87 |
| 2021 Agosto | 23 | 16 | 39 |
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