Vidar Ruddox

Atrial fibrillation and the risk for myocardial infarction, all-cause mortality and heart failure: A systematic review and meta-analysis

Background In contemporary atrial fibrillation trials most deaths are cardiac related, whereas stroke and bleeding represent only a small subset of deaths. We aimed to evaluate the long-term risk of cardiac events and all-cause mortality in individuals with atrial fibrillation compared to no atrial fibrillation. Design A systematic review and meta-analysis of studies published between 1 January 2006 and 21 October 2016. Methods Four databases were searched. Studies had follow-up of at least 500 stable patients for either cardiac endpoints or all-cause mortality for 12 months or longer. Publication bias was evaluated and random effects models were used to synthesise the results. Heterogeneity between studies was examined by subgroup and meta-regression analyses. Results A total of 15 cohort studies was included. Analyses indicated that atrial fibrillation was associated with an increased risk of myocardial infarction (relative risk (RR) 1.54, 95% confidence interval (CI) 1.26–1.85), all-cause mortality (RR 1.95, 95% CI 1.50–2.54) and heart failure (RR 4.62, 95% CI 3.13–6.83). Coronary heart disease at baseline was associated with a reduced risk of myocardial infarction and explained 57% of the heterogeneity. A prospective cohort design accounted for 25% of all-cause mortality heterogeneity. Due to there being fewer than 10 studies, sources of heterogeneity were inconclusive for heart failure. Conclusions Atrial fibrillation seems to be associated with an increased risk of subsequent myocardial infarction in patients without coronary heart disease and an increased risk of, all-cause mortality and heart failure in patients with and without coronary heart disease.

In Current Clinical Practice, after Percutaneous Coronary Intervention for Acute Myocardial Infarction, Are β-Blockers Prescribed for Heart Failure or as Secondary Prevention? A Pilot Study

Objectives: Patients surviving an acute myocardial infarction (AMI) are different today than when oral β-blockers first were shown to have an incremental effect on mortality. They are now, as opposed to then, offered revascularization procedures and effective secondary prevention. In this pilot-study, we aimed to explore the prescription of β-blockers to these patients stratified by their left ventricular ejection fraction (LVEF). Methods: Consecutive stable patients treated with a percutaneous coronary intervention (PCI) procedure following an AMI were included for measurement of LVEF after 1–5 days. β-Blocker treatment was recorded at inclusion and after 3 months. Results: We included 159 patients, 89% with LVEF ≥40% (56% had a LVEF ≥50% [preserved], 33% LVEF 40–49% [mid-range] and 11% LVEF <40% [reduced]). At discharge the prescription rates of β-blockers according to LVEF stratification were 79% for preserved, 79% for mid-range and 94% for reduced LVEF. After 3 months 72% of all patients continued such treatment. Conclusions: In this prospective study, a large proportion of contemporary managed patients with AMI but without clinical heart failure does not have reduced LVEF shortly after PCI, but the majority is still treated with a β-blocker.

Effect of oral β-blocker treatment on mortality in contemporary post-myocardial infarction patients: a systematic review and meta-analysis

Abstract Aims Guidelines concerning β-blocker treatment following acute myocardial infarction (AMI) are based on studies undertaken before the implementation of reperfusion and secondary prevention therapies. We aimed to estimate the effect of oral β-blockers on mortality in contemporary post-AMI patients with low prevalence of heart failure and/or reduced left ventricular ejection fraction. Methods and results A random effects model was used to synthetize results of 16 observational studies published between 1 January 2000 and 30 October 2017. Publication bias was evaluated, and heterogeneity between studies examined by subgroup and random effects meta-regression analyses considering patient-related and study-level variables. The pooled estimate showed that β-blocker treatment [among 164 408 (86.8%) patients, with median follow-up time of 2.7 years] was associated with a 26% reduction in all-cause mortality [rate ratio (RR) 0.74, 95% confidence interval (CI) 0.64–0.85] with moderate heterogeneity (I2 = 67.4%). The patient-level variable mean age of the cohort explained 31.5% of between study heterogeneity. There was presence of publication bias, or small study effect, and when controlling for bias by the trim and fill simulation method, the effect disappeared (adjusted RR 0.90, 95% CI 0.77–1.04). Also, small study effect was demonstrated by a cumulative meta-analysis starting with the largest study showing no effect, with increasing effect as the smaller studies were accumulated. Conclusion Evidence from this study suggests that there is no association between β-blockers and all-cause mortality. A possible beneficial effect in AMI survivors needs to be tested by large randomized clinical trials.