Absence of Prophylactic Effect of Propranolol in Myocardial Infarction

Clausen, Jan; Felsby, M.; Jørgensen, F.; Nielsen, Bent; J, Roin; Strange, B

doi:10.1016/s0140-6736(66)90533-2

Cited by 118 publications

(16 citation statements)

References 13 publications

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“…There was significant heterogeneity in the mortality rates (0% 10,12 to 37% 4 ) between the control groups. Although the three studies with the highest control mortality rates (37,4 33.9, 8 and 24.1% 7 ) were those with 100% MIs, these high rates do not appear to be the result of a selection bias in choosing MI versus non-MI patients. Many trials with 100% MI patients also had very low control group mortality rates (0, 12 1.2, 20 and 2.1% 17 ).…”

Section: Trial Qualitymentioning

confidence: 81%

“…The 18 articles that met all criteria make up the basis for this evidence-based medicine review. 4,[7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] There were several large and often-quoted studies using beta-blockers in acute myocardial infarction that did not meet our strictly time-limited inclusion criteria. The Beta-Blocker Heart Attack trial 24 was a randomized double-blinded multicenter study of propanolol given to patients (n = 3,837) at least 5 days post-MI and followed for 2 to 4 years.…”

Section: Search Resultsmentioning

confidence: 99%

“…Propanolol was the most commonly used beta-blocker (7 ⁄ 18 studies), 4,7,8,[10][11][12]15 followed by metroprolol (4 ⁄ 18 studies), 16,18,21,23 atenolol (3 ⁄ 18 studies), 13,19,22 practolol (1 ⁄ 18 studies), 9 pindolol (1 ⁄ 18 studies), 17 timolol (1 ⁄ 18 studies), 14 and labetalol (1 ⁄ 18 studies). 20 …”

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confidence: 99%

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Does the Early Administration of Beta‐blockers Improve the In‐hospital Mortality Rate of Patients Admitted with Acute Coronary Syndrome?

Brandler

Paladino

Sinert

2010

Academic Emergency Medicine

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Objectives: Beta-blockade is currently recommended in the early management of patients with acute coronary syndromes (ACS). This was a systematic review of the medical literature to determine if early beta-blockade improves the outcome of patients with ACS. Methods:The authors searched the PubMed and EMBASE databases for randomized controlled trials from 1965 through May 2009 using a search strategy derived from the following PICO formulation of our clinical question: Patients included adults (18+ years) with an acute or suspected myocardial infarction (MI) within 24 hours of onset of chest pain. Intervention included intravenous or oral beta-blockers administered within 8 hours of presentation. The comparator included standard medical therapy with or without placebo versus early beta-blocker administration. The outcome was the risk of in-hospital death in the intervention groups versus the comparator groups. The methodologic quality of the studies was assessed. Qualitative methods were used to summarize the study results. In-hospital mortality rates were compared using a forest plot of relative risk (RR; 95% confidence interval [CI]) between beta-blockers and controls. Statistical analysis was done with Review Manager V5.0.Results: Eighteen articles (total N = 72,249) met the inclusion ⁄ exclusion criteria. For in-hospital mortality, RR = 0.95 (95% CI, 0.90-1.01). In the largest of these studies (n = 45,852), a significantly higher rate (p < 0.0001) of cardiogenic shock was observed in the beta-blocker (5.0%) versus control group (3.9%).Conclusions: This systematic review failed to demonstrate a convincing in-hospital mortality benefit for using beta-blockers early in the course of patients with an acute or suspected MI. ACADEMIC EMERGENCY MEDICINE 2010; 17:1-10 ª 2010 by the Society for Academic Emergency MedicineKeywords: adrenergic beta-antagonists, coronary artery disease, chest pain, myocardial infarction, angina CLINICAL SCENARIOA 48-year-old man presents to the emergency department (ED) with new onset chest pain of 45 minutes' duration that occurred for the first time today. The pain was centrally located in the chest when it began and did not radiate. It dissipated after 10 minutes of rest and is no longer present at the time of evaluation. The pain was associated with some shortness of breath, but no nausea, vomiting, diaphoresis, or palpitations. The patient has hypertension and non-insulin-dependent diabetes and has smoked 1 to 1.5 packs of cigarettes per day for 20 years. His father died of a heart attack at age 45. The physical exam and vital signs are all within normal limits. The heart rate is 95 beats ⁄ min, blood pressure is 170 ⁄ 94 mm Hg, and finger stick blood sugar is 230 mg ⁄ dL. An electrocardiogram demonstrated deep and symmetrical T-wave inversions in the precordial leads V4-V6. The initial troponin is normal. The patient receives aspirin, and you decide to admit him to the telemetry unit for possible acute coronary syndrome (ACS). The patient's family physician requests that yo...

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Section: Trial Qualitymentioning

confidence: 81%

Section: Search Resultsmentioning

confidence: 99%

See 1 more Smart Citation

Does the Early Administration of Beta‐blockers Improve the In‐hospital Mortality Rate of Patients Admitted with Acute Coronary Syndrome?

Brandler

Paladino

Sinert

2010

Academic Emergency Medicine

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“…Figures 1 and 2 show the mortality rate to depend closely on the time elapsed from the onset of symptoms. These data have since been confirmed by several authors: 60% of infarction deaths occur within the first 2 h and 85% within 24 h [1,28,66], The data tabulated by Kuller [1969] is relevant also: Unfortunately, these results have not been confirmed in 4 subsequent studies which involved a large number of patients in both groups [2,9,37,38].…”

Section: Inhibition O F the ¡3-adrenergic Receptorsmentioning

confidence: 91%

The Difficulty of Appraisal of Streptokinase Treatment of Myocardial Infarction

Verstraete¹

1971

J Vasc Res

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Considerable advances have been made in clinical pharmacology of late, permitting more precise evaluation of new drugs. This must be taken into account in assessing the thrombolytic therapy of acute myocardial infarction. Clinical trials necessitate control groups, which must in volve a sufficiently large number of patients so that differences are not due to chance. To be valid, the groups must be strictly comparable. It is essential to define precisely criteria for admission and contraindications, if possible stratifying the patients, since the final evaluation must include all patients according to the treatment originally allocated. For recent myocardial infarction, it is important to compare thrombolytic therapy with the best treatment currently available, the patients being randomly allocated to these alternatives. However, it is not clear whether the best current treatment is anticoagulation, polarizing solutions (combining glucose, insulin and potassium), prophylactic antiarrhythmic drugs (procainamide, lignocaine) or <i>β</i>-adrenergic inhibitors (propranolol), and therefore which to use in comparison. The trend to coronary care units already has shown a reduction in mortality, perhaps necessitating evaluation of thrombolytic therapy only in such units. If thrombolysis finds a place in the management of myocardial infarction, treatment must start within the first hours following onset of symptoms. This increases the likelihood that patients diagnosed erroneously also will be treated with thrombolytic agents. Reassurance is needed that such treatment is harmless in these circumstances. Lastly, the statistical interpretation of the value of thrombolytic therapy must be regarded as a ‘two-tailed’ situation.

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“…The situation is further complicated by the fact that infarction may be associated with reduction in liver blood flow and hepatic enzyme function which could also affect the elimination of propranolol. Despite early enthusiasm concerning the use of fl-adrenoceptor blockers in myocardial infarction several trials in the late 1960's failed to show an effect on mortality (Balcon, Jewitt, Davies & Oram, 1966;Clausen, Felsby, Jorgensen, Nielsen, Roin & Strange, 1966;Multicentre Trial, 1966). Since these negative studies used small doses by modern standards (20 mg, 6 hourly) they may not have achieved adequate therapeutic levels.…”

Section: Increased Plasma Propranolol Binding In Myocardial Infarctionmentioning

confidence: 99%