Beta-Blockers after Myocardial Infarction and Preserved Ejection Fraction.

BACKGROUND: Most trials that have shown a benefit of beta-blocker treatment after myocardial infarction included patients with large myocardial infarctions and were conducted in an era before modern biomarker-based diagnosis of myocardial infarction and treatment with percutaneous coronary intervention, antithrombotic agents, high-intensity statins, and renin-angiotensin-aldosterone system antagonists. METHODS: In a parallel-group, open-label trial performed at 45 centers in Sweden, Estonia, and New Zealand, we randomly assigned patients with an acute myocardial infarction who had undergone coronary angiography and had a left ventricular ejection fraction of at least 50% to receive either long-term treatment with a beta-blocker (metoprolol or bisoprolol) or no beta-blocker treatment. The primary end point was a composite of death from any cause or new myocardial infarction. RESULTS: From September 2017 through May 2023, a total of 5020 patients were enrolled (95.4% of whom were from Sweden). The median follow-up was 3.5 years (interquartile range, 2.2 to 4.7). A primary end-point event occurred in 199 of 2508 patients (7.9%) in the beta-blocker group and in 208 of 2512 patients (8.3%) in the no-beta-blocker group (hazard ratio, 0.96; 95% confidence interval, 0.79 to 1.16; P = 0.64). Beta-blocker treatment did not appear to lead to a lower cumulative incidence of the secondary end points (death from any cause, 3.9% in the beta-blocker group and 4.1% in the no-beta-blocker group; death from cardiovascular causes, 1.5% and 1.3%, respectively; myocardial infarction, 4.5% and 4.7%; hospitalization for atrial fibrillation, 1.1% and 1.4%; and hospitalization for heart failure, 0.8% and 0.9%). With regard to safety end points, hospitalization for bradycardia, second- or third-degree atrioventricular block, hypotension, syncope, or implantation of a pacemaker occurred in 3.4% of the patients in the beta-blocker group and in 3.2% of those in the no-beta-blocker group; hospitalization for asthma or chronic obstructive pulmonary disease in 0.6% and 0.6%, respectively; and hospitalization for stroke in 1.4% and 1.8%. CONCLUSIONS: Among patients with acute myocardial infarction who underwent early coronary angiography and had a preserved left ventricular ejection fraction (≥50%), long-term beta-blocker treatment did not lead to a lower risk of the composite primary end point of death from any cause or new myocardial infarction than no beta-blocker use. (Funded by the Swedish Research Council and others; REDUCE-AMI ClinicalTrials.gov number, NCT03278509.).

Corrigendum to "Long-term mortality and morbidity among 30-day survivors after in-hospital cardiac arrests-A Swedish cohort study" [Resuscitation 124 (2018) 76-79].

OBJECTIVES: Resuscitation on in-hospital cardiac arrest (IHCA) is estimated to occur in 200,000 hospitalised patients annually in the US and short-term survival, i.e. 30 days, is reported to be around 15-20%. Even if 30-day survival is a good measure of successful resuscitation, the number of survivors is quite high and a perspective on longer-term outcomes is relevant. AIM: To assess long-term mortality among 30-day survivors after an IHCA. MATERIAL AND METHODS: All patients ≥18 years surviving for at least 30 days after an IHCA at Karolinska University Hospital between 1st January 2007 and 31st December 2014 were included. Data regarding the IHCA, patient characteristics, new cardiac, pulmonary or neurological diagnosis and death dates were obtained from complete Swedish national registries. Censor date was set as 10th February 2017. Differences in long-term survival between those with shockable compared to those with non-shockable first rhythm were assessed with Kaplan Meier survival curves, with adjustment for age-adjusted Charlson Co-morbidity Index (AccI). RESULTS: In all, 1019 patients suffered an IHCA, of whom 267 (26%) survived for at least 30 days. Out of the 267 patients, 158 (59%) were still alive at the censor date, i.e. 3-10 years after their IHCA. The three year survival ratio was 72%. There was a significant better long-term survival among those with shockable initial rhythm than those with a non-shockable first rhythm that persisted after adjustment for ACCI (adjusted 10-year survival; >75% and >50% respectively, p-value < .01). CONCLUSION: In conclusion, long-term survival after an IHCA is quite good irrespective of initial rhythm but is related to the burden of baseline co-morbidities.

Long-term mortality and morbidity among 30-day survivors after in-hospital cardiac arrests - a Swedish cohort study.

OBJECTIVES: Resuscitation on in-hospital cardiac arrest (IHCA) is estimated to occur in 200,000 hospitalised patients annually in the US and short-term survival, i.e. 30 days, is reported to be around 15-20%. Even if 30-day survival is a good measure of successful resuscitation, the number of survivors is quite high and a perspective on longer-term outcomes is relevant. AIM: To assess long-term mortality among 30-day survivors after an IHCA. MATERIAL AND METHODS: All patients ≥18 years surviving for at least 30 days after an IHCA at Karolinska University Hospital between 1st January 2007 and 31st December 2014 were included. Data regarding the IHCA, patient characteristics, new cardiac, pulmonary or neurological diagnosis and death dates were obtained from complete Swedish national registries. Censor date was set as 10th February 2017. Differences in long-term survival between those with shockable compared to those with non-shockable first rhythm were assessed with Kaplan Meier survival curves, with adjustment for age-adjusted Charlson Co-morbidity Index (ACCI). RESULTS: In all, 1019 patients suffered an IHCA, of whom 267 (26%) survived for at least 30 days. Out of the 267 patients, 158 (59%) were still alive at the censor date, i.e. 3-10 years after their IHCA. There was a significant better long-term survival among those with shockable initial rhythm than those with a non-shockable first rhythm that persisted after adjustment for ACCI (adjusted 10-year survival; >75% and >50% respectively, p-value <0.01). CONCLUSION: In conclusion, long-term survival after an IHCA is quite good irrespective of initial rhythm but is related to the burden of baseline co-morbidities.

Trends in co-morbidities and survival for in-hospital cardiac arrest -A Swedish cohort study.

OBJECTIVES: Co-morbidities affect survival after in-hospital cardiac arrests (IHCA). The risk population for IHCA, i.e. the hospitalised patients, have a doubled increase in co-morbidities over time. A similar increase in co-morbidities among IHCAs might explain the relatively poor survival ratios despite improved care. AIM: To assess changes in the burden of baseline age-adjusted Charlson co-morbidity index (ACCI) scores among IHCAs as well as to assess its impact on survival in three time periods. MATERIAL AND METHODS: All patients ≥18 years suffering an IHCA at Karolinska University Hospital between 1st January 2007 and 31st December 2015 were included. Data regarding the IHCA, patient characteristics, ACCI and 30 day survival were obtained from electronic patient records. Parameters included in ACCI were assessed as ICD-10 codes in the medical file at admission to hospital. The median ACCI with interquartile range (IQR) was presented per year. ACCI was categorised into low 0-2points, moderate 3-5points, high 6-8 points and very high ≥9 points. Differences in survival between 2007 and 2009 and 2010-2012 as well as 2013-2015 were stratified per ACCI category and assessed with adjusted logistic regression models and presented as Odds Ratios with 95% Confidence Intervals (OR, 95% CI). Adjustments included hospital site, sex, first rhythm, ECG-surveillance, witnessed or not, and location of the IHCA. RESULTS: In all, 1373 patients suffered an IHCA, of whom 376 (27%) survived at least 30 days. The ACCI remained almost constant over time at median 4, IQR 3-6. Patients with low or moderate ACCI more than doubled their survival in 2013-2015 compared to 2007-2009 (adjusted OR 2.61 95% CI1.38-4.94 and OR 1.87 95% CI 1.14-3.09 respectively). CONCLUSION: This cohort study illuminates an almost constant burden of co-morbidities over time among patients suffering an IHCA. Further, the study highlights that 30-day survival has almost doubled from 2007 to 2009 to 2013-2015 among those with low to moderate AccI.