Beta-blocker efficacy across different cardiovascular indications: an umbrella review and meta-analytic assessment

Abstract

Background: Beta-blockers are widely used for many cardiovascular conditions; however, their efficacy in contemporary clinical practice remains uncertain. Methods: We performed a prospectively designed, umbrella review of meta-analyses of randomised controlled trials (RCTs) investigating the evidence of beta-blockers in the contemporary management of coronary artery disease (CAD), heart failure (HF), patients undergoing surgery or hypertension (registration: PROSPERO CRD42016038375). We searched MEDLINE, EMBASE and the Cochrane Library from inception until December 2018. Outcomes were analysed as beta-blockers versus control for all-cause mortality, myocardial infarction (MI), incident HF or stroke. Two independent investigators abstracted the data, assessed the quality of the evidence and rated the certainty of evidence. Results: We identified 98 meta-analyses, including 284 unique RCTs and 1,617,523 patient-years of follow-up. In CAD, 12 meta-analyses (93 RCTs, 103,481 patients) showed that beta-blockers reduced mortality in analyses before routine reperfusion, but there was a lack of benefit in contemporary studies where ≥ 50% of patients received thrombolytics or intervention. Beta-blockers reduced incident MI at the expense of increased HF. In HF with reduced ejection fraction, 34 meta-analyses (66 RCTs, 35,383 patients) demonstrated a reduction in mortality and HF hospitalisation with beta-blockers in sinus rhythm, but not in atrial fibrillation. In patients undergoing surgery, 23 meta-analyses (89 RCTs, 19,211 patients) showed no effect of beta-blockers on mortality for cardiac surgery, but increased mortality in non-cardiac surgery. In non-cardiac surgery, beta-blockers reduced MI after surgery but increased the risk of stroke. In hypertension, 27 meta-analyses (36 RCTs, 260,549 patients) identified no benefit versus placebo, but beta-blockers were inferior to other agents for preventing mortality and stroke. Conclusions: Beta-blockers substantially reduce mortality in HF patients in sinus rhythm, but for other conditions, clinicians need to weigh up both benefit and potential risk.

Evaluation of the prescribing practice of guideline-directed medical therapy among ambulatory chronic heart failure patients

“…While there is significant evidence for HFrEF management, there is a lack of evidence-based pharmacotherapies for HFpEF [ 8 ]. Guideline-recommended pharmacotherapies for HFrEF such as ACEIs/ARBs [ 14 , 15 ], β-blockers [ 16 , 17 ], and MRAs [ 18 ] have limited benefits in HFpEF, [ 19 ] and HFmrEF [ 20 ], likely reflecting the different underlying pathophysiological processes. Studies looking to further characterize the pathophysiology, patient’s demographics and clinical characteristics in the development of strategies for the management of HFpEF and HFmrEF categories are ongoing [ 21 ].…”

Effect of Digoxin vs Bisoprolol for Heart Rate Control in Atrial Fibrillation on Patient-Reported Quality of Life

“…6,7 Heart rate control in patients with AF and suspected or diagnosed heart failure is usually limited to a β-blocker, digoxin, or their combination. 8 β-Blockers are most widely used due to experience in other cardiovascular conditions 9 and in heart failure with reduced ejection fraction in particular because prognosis is improved in patients with sinus rhythm regardless of age or sex. 10 However, this finding was not replicated in the subgroup of patients with AF.…”

Non-genetic risk and protective factors and biomarkers for neurological disorders: a meta-umbrella systematic review of umbrella reviews

“…Several umbrella reviews have analyzed the risk and protective factors for a certain disease or condition, or the effects of some of these factors on multiple health outcomes, based on meta-analyses or Mendelian randomization studies [43], diagnostic criteria, and screening tools [44], diagnostic accuracy studies [45], therapeutic interventions [46], clinical efficacy of drugs [47], and/or interactions between genetic and environmental factors [48]. With regard to brain health, several umbrella reviews have analyzed meta-analyses and systematic reviews reporting an association between environmental factors and a single non-communicable neurological disorder (e.g., the risk factors for MS) [49][50][51], while others have studied the roles of a single factor (e.g., vitamin D levels) into multiple health outcomes, including neurological disorders [52].…”