Clinical Outcomes with β-Blockers for Myocardial Infarction: A Meta-analysis of Randomized Trials

Bangalore, Sripal; Makani, Harikrishna; Radford, Martha J.; Thakur, Kalpna; Toklu, Bora; Katz, Stuart D.; DiNicolantonio, James J.; Devereaux, P. J.; Alexander, Karen P.; Wetterslev, Jørn; Messerli, Franz H.

doi:10.1016/j.amjmed.2014.05.032

Cited by 249 publications

(147 citation statements)

References 61 publications

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“…Several randomized clinical trials in this subset of patients have shown an improvement in angina associ ated with a reduction in cardiovascular mortality and sudden death 30,31 .…”

Section: Key Points For β-Blockersmentioning

confidence: 97%

“…When chronic stable angina is present in patients with left ventricular systolic dysfunction with or without overt heart failure, the overwhelming, evidence-based indication is to use β-blockers, which can reduce chronic stable angina and, at the same time, effectively reduce cardiovascular morbidity and mortality in these patients 30,31 . These beneficial effects seem to be directly correlated with a heart-rate-lowering effect of β-blockers; therefore, β-blockers with intrinsic sympathetic activity should be avoided.…”

Section: Guideline Recommendationsmentioning

confidence: 99%

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A 'diamond' approach to personalized treatment of angina

et al. 2017

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Chronic stable angina pectoris is the most prevalent symptomatic manifestation of ischaemic heart disease, and its management is a priority (BOX 1). Current clinical guidelines recommend antianginal therapy to control symptoms, before considering coronary artery revasculariza tion [1][2][3][4] . However, revascularization by either percutaneous coronary angioplasty or CABG surgery is indicated in patients who have significant artery steno sis (50% left main narrowing or proximal three-vessel disease) to reduce myocardial ischaemia and its adverse clinical manifestation. Antianginal agents are approved by documenting that they improve total exercise duration, together with a reduction in daily frequency of chronic stable angina compared with placebo and/or equivalence to an active comparator. Cardiovascular outcomes, although highly advocated, are not a pre requisite for regulatory approval. None of the antianginal drugs has been proved to reduce cardiovascular mortality or the rate of myocardial infarction. When patients are optimally treated, mortality for chronic stable angina is low, which might explain why all trials designed to improve prognosis have been negative. Guidelines recom mend a first-choice and a second-choice approach, based more on tradition and expert opinion, rather than evidence. This categorical approach has been questioned in the past couple of years 5-8 . Newer antianginal drugs, which are classified as second choice, have more evidence-based clinical data that are more contemporary to support their use than is available for the traditional first-choice drugs. Equally, the often-needed combin ation of double or triple therapy is based on expert opinion and not related to the underlying pathophysio logy. What constitutes optimal antianginal treatment, therefore, varies considerably between countries, and the majority of doctors treat their patients according to their own preconceptions.A group of experts with experience and interest in chronic stable angina met at the University of Ferrara, Italy, to discuss an individualized approach to medical treatment of chronic stable angina, on the basis E X P E RT C O N S E N S U S D O C U M E N TA 'diamond' approach to personalized treatment of angina Abstract | In clinical guidelines, drugs for symptomatic angina are classified as being first choice (β-blockers, calcium-channel blockers, short-acting nitrates) or second choice (ivabradine, nicorandil, ranolazine, trimetazidine), with the recommendation to reserve second-choice medications for patients who have contraindications to first-choice agents, do not tolerate them, or remain symptomatic. No direct comparisons between first-choice and second-choice treatments have demonstrated the superiority of one group of drugs over the other. Meta-analyses show that all antianginal drugs have similar efficacy in reducing symptoms, but provide no evidence for improvement in survival. The newer, second-choice drugs have more evidence-based clinical data that are more contemporary than is available for tr...

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“…Several randomized clinical trials in this subset of patients have shown an improvement in angina associ ated with a reduction in cardiovascular mortality and sudden death 30,31 .…”

Section: Key Points For β-Blockersmentioning

confidence: 97%

Section: Guideline Recommendationsmentioning

confidence: 99%

A 'diamond' approach to personalized treatment of angina

et al. 2017

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“…-Újabban egyre több irodalmi adat megkérdőjelezi a béta-blokkolók szükségességét [23]. -A beteg nem váltja ki a felírt gyógyszereit (betegcompliance).…”

Section: öSszefoglaló Közleményunclassified

A háziorvosok teljesítményének minőségi értékelése. Mi a probléma a háziorvosi indikátorokkal?

Kolozsvári

Rurik

2016

Orvosi Hetilap

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Magyarországon a háziorvosi indikátorrendszert 2009-ben vezették be és azóta folyamatosan fejlesztik. A rendszer bizonyos számszerű elvárások alapján többletfinanszírozást ad a mérőszámokban jobban teljesítő háziorvosoknak. A szerzők a jelenleg használatos 16 felnőtt-és vegyes, valamint a 8 gyermekkörzeti indikátort elemzik, és rámutatnak azokra a tényezőkre, amelyek a háziorvosok munkáján kívül a mérőszámokat befolyásolják. A legfontosabbak: a betegek elvárásai, compliance-ük, a szakellátók tevékenysége, a szolgáltatók közötti nem megfelelő információáramlás és a nem megfelelő háziorvosi szoftver, amelynek fejlesztése szükséges. A szerzők véleménye szerint az anyagi motiváció szintjét is a jelenlegi többszörösére kellene emelni, a jelentési rendszer megváltoztatása mellett. Javasolják, hogy a szakmapolitikai és finanszírozói elvárások megfogalmazásával szakmai grémiumok alakítsák ki az indikátorokat, amelyeket fontosnak tartanak a hazai alapellátás színvonalának emeléséhez. Orv. Hetil., 2016, 157(9), 328-335. Kulcsszavak: alapellátás, finanszírozás, indikátorok, minőség, teljesítményértékelés Quality evaluation of primary care service performance What are the problems with the recent Hungarian primary care indicators?The Hungarian primary care quality indicator system has been introduced in 2009, and has been continuously developed since then. The system offers extra financing for family physicians who are achieving the expected levels of indicators. There are currently 16 indicators for adult and mixed practices and 8 indicators are used in paediatric care. Authors analysed the influencing factors of the indicators other than those related to the performance of family physicians. Expectations and compliance of patients, quality of outpatient (ambulatory) care services, insufficient flow of information, inadequate primary care softwares which need to be updated could be considered as the most important factors. The level of financial motivations should also be significantly increased besides changes in the reporting system. It is recommended, that decision makers in health policy and financing have to declare clearly their expectations, and professional bodies should find the proper solution. These indicators could contribute properly to the improvement of the quality of primary care services in Hungary.

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“…The authors of the review also perform further analysis (ie, trial sequential analysis) to ensure that the number of patients allowed sufficient power to draw their conclusions. 15 The reperfusion strata had a sample size of 48,806 patients and 99% power to detect a difference between intervention and control.…”

Section: 2mentioning

confidence: 99%

“…Despite these data, β-blockers retained a high-class recommendation in major expert guidelines, and registry data suggested that the publication of the COMMIT results did not result in a significant change in β-blocker practice patterns in acute MI. 14 To help inform the impact of contemporary treatment on the efficacy of β-blocker in acute MI, Bangalore et al 15 undertook a systematic review and meta-analysis. Randomized controlled trials comparing β-blockers with controls in patients with MI were included in the systematic review.…”

Section: 2mentioning

confidence: 99%