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CLINICAL RESEARCH: BETA-BLOCKERS IN MYOCARDIAL INFARCTION

Impact of intravenous Beta-Blockade before primary angioplasty on survival in patients undergoing mechanical reperfusion therapy for acute myocardial infarction

Amir Halkin, MD^*, Cindy L. Grines, MD, FACC, David A. Cox, MD, FACC, Eulogio Garcia, MD, Roxana Mehran, MD, FACC^*, James E. Tcheng, MD, FACC^||, John J. Griffin, MD, FACC^¶, Giulio Guagliumi, MD^#, Bruce Brodie, MD, FACC^**, Mark Turco, MD, FACC, Barry D. Rutherford, MD, FACC, Eve Aymong, MD^*, Alexandra J. Lansky, MD, FACC^* and Gregg W. Stone, MD, FACC^*,*

^* Cardiovascular Research Foundation and Lenox Hill Heart and Vascular Institute, New York, New York, USA
William Beaumont Hospital, Royal Oak, Michigan, USA
Mid Carolina Cardiology, Charlotte, North Carolina, USA
Hospital Gregorio Maranon, Madrid, Spain
^|| Duke Clinical Research Institute, Durham, North Carolina, USA
^¶ Virginia Beach General Hospital, Virginia Beach, Virginia, USA
^# Ospedali Riuniti di Bergamo, Bergamo, Italy
^** Moses Cone Memorial Hospital, Greensboro, North Carolina, USA
Washington Adventist Hospital, Tacoma Park, Maryland, USA
St. Luke's Hospital, Kansas City, Missouri, USA

Manuscript received August 13, 2003; revised manuscript received October 13, 2003, accepted October 20, 2003.

^* Reprint requests and correspondence: Dr. Gregg W. Stone, The Cardiovascular Research Foundation, 55 East 59th Street, 6th Floor, New York City, New York 10022, USA.
gstone{at}crf.org

OBJECTIVES: We sought to examine the effect of intravenous beta-blockers administered before primary percutaneous coronary intervention (PCI) on survival and myocardial recovery after acute myocardial infarction (AMI).

BACKGROUND: Studies of primary PCI but not thrombolysis have suggested that beta-blocker administration before reperfusion may enhance survival. Whether oral beta-blocker use before admission modulates this effect is unknown.

METHODS: The Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial randomized 2,082 AMI patients to either stenting or balloon angioplasty, each ± abciximab. In accordance with the protocol, intravenous beta-blockers were administered before PCI in the absence of contraindications.

RESULTS: A total of 1,136 patients (54.5%, BB+ group) received beta-blockers before PCI, whereas 946 (45.5%, BB– group) did not. The 30-day mortality was significantly lower in the BB+ group than in the BB– group (1.5% vs. 2.8%, p = 0.03), an effect entirely limited to patients who had not been receiving beta-blockers before admission (1.2% vs. 2.9%, p = 0.007). In contrast, no survival benefit with pre-procedural beta-blockers was observed in patients receiving beta-blockers at home (3.3% vs. 1.9%, respectively, p = 0.47). By multivariate analysis, pre-procedural beta-blocker use was an independent predictor of lower 30-day mortality among patients without previous beta-blocker therapy (relative risk = 0.38 [95% confidence interval 0.17 to 0.87], p = 0.02). The improvement in left ventricular ejection fraction from baseline to seven months was also greater after intravenous beta-blockers (3.8% vs. 1.3%, p = 0.01), an effect limited to patients not receiving oral beta-blockers before admission.

CONCLUSIONS: In patients with AMI undergoing primary PCI, myocardial recovery is enhanced and 30-day mortality is reduced with pre-procedural intravenous beta-blockade, effects confined to patients untreated with oral beta-blocker medication before admission.

Abbreviations and Acronyms   AMI = acute myocardial infarction   CADILLAC = Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications   CI = confidence interval   HR = hazard ratio   LVEF = left ventricular ejection fraction   PAMI = Primary Angioplasty in Myocardial Infarction   PCI = percutaneous coronary intervention   TIMI = Thrombolysis In Myocardial Infarction

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