BEtablocker Treatment After Acute Myocardial Infarction in Patients Without Reduced Left Ventricular Systolic Function (BETAMI)

February 29, 2024 updated by: Dan Atar, Oslo University Hospital

BEtablocker Treatment After Acute Myocardial Infarction in Patients Without Reduced Left Ventricular Systolic Function (BETAMI)

The study aims to investigate whether oral betablocker (BB) therapy is superior to no such treatment following an acute myocardial infarction (AMI).

Study Overview

Detailed Description

This is a prospective, randomized, open blinded end-point (PROBE) study. Patients with AMI will be randomized 1-8 days following PCI or thrombolysis, and allocated to either prescription of a BB or to no such prescription. Subjects will be followed up for at least 6 months (median 3 years) with respect to the primary and secondary endpoints.

The primary objective is to test whether oral BB therapy reduces the risk of all-cause death, recurrent MI, incident heart failure, coronary revascularization, ischemic stroke, malignant ventricular arrhythmia or resuscitated cardiac arrest compared to no such therapy, in patients with AMI treated with PCI or thrombolysis without reduced LVEF.

The key secondary objectives are:

  • To study whether oral BB therapy reduces the risk of each of the components of the primary end-point separately, compared to no such therapy
  • To assess clinical outcomes linked BB therapy in the following subgroups: age (tertiles), gender (men vs. women), BB dosage tertiles (dosage at randomization, STEMI vs. NSTEMI, and LVEF subgroups (preserved LVEF: ≥50% vs. mid-range LVEF: 40-49%).

Other secondary objectives are:

  • To study whether oral BB therapy reduces the risk of cardiovascular death compared to no such therapy
  • To study whether oral BB therapy reduces the risk of stable and unstable angina compared to no such therapy
  • To study whether oral BB therapy reduces the risk of atrial fibrillation, atrial flutter or other atrial tachyarrhythmias compared to no such therapy
  • To study whether oral BB therapy increases the risk of hospitalization for bradycardia, syncope, implantation of pacemaker.
  • To study whether oral BB therapy increases the risk of hospitalization for chronic obstructive pulmonary disease, asthma or peripheral artery disease.
  • To study whether oral BB therapy increases the risk of hospitalization or outpatient visit for new-onset or dysregulated diabetes
  • To study whether oral BB therapy affects the following patient related outcomes:

quality of life, angina, dyspnoea, anxiety, depression, sexual dysfunction or sleep disorders

  • To describe BB dosage and adherence obtained from the national prescription registries
  • To study sociodemographic, clinical, and psychosocial characteristics (PROMS and clinical data) between the two study arms and in the total sample
  • To conduct cost-utility analysis in relation to quality of life and a health economic evaluation including drug use, health care utilization, employment, income, and benefit take-up
  • To assess study safety

Exploratory objectives:

  • To study the proportion and predictors of non-adherence with BB, statins and other cardiovascular drugs assessed by direct methods quantifying drug concentrations in blood
  • Identify pharmacokinetic, pharmacogenetic and pharmacodynamic markers associated with side-effects and suboptimal response to treatment with cardiovascular drugs

The primary study end-points will be obtained through linkage to the Norwegian Cardiovascular Disease Registry and The Norwegian Population Registry (Folkeregisteret)

Secondary endpoints will be obtained by linkage to the following national registries: The Norwegian Population Registry (Folkeregisteret), the Cause of Death Registry, the Norwegian Patient Registry, the Norwegian Cardiovascular Disease Registry, the Norwegian Prescription Database, the Norwegian registry for income, the FD-Trygd database (social security micro data for research) and the Control and payment of reimbursements to health service providers (KUHR) database. Further by collecting self-reported questionnaires and a clinical examination with blood sample collection.

Primary safety endpoints:

• To describe the composite endpoint of malignant ventricular arrhythmias or resuscitated cardiac arrest, incident heart failure, new MI or all-cause death at 30 days after randomization collected from i. direct telephone contact with the patient and from hospital medical records, ii. linkage to the Norwegian Cardiovascular Disease Registry and The Norwegian Population Registry at study end.

Other safery endpoints:

  • To describe all-cause death at study end
  • To describe Suspected Unexpected Serious Adverse Reaction (SUSARs) during the follow-up period from the study database (continously reported by local investigators).

Rationale for combining data from the BETAMI study with the DANBLOCK (NCT03778554) study from Denmark: The trials have similar designs, only minor differences in study entry criteria, and were, from the very beginning, coordinated with the aim of conducting sub-studies on pooled data. However, the inclusion- and event rates have been lower than expected in both studies. To enhance feasibility, the final decision was made from both Steering Committees in March 2022 to combine the trials and publish initial results jointly. BETAMI and DANBLOCK will remain separate trials until the end of follow-up, where data from the trials will be combined and main results published together.

Sample size: A total of approximately 2900 patients from BETAMI will be recruited and randomized 1:1 to BB treatment (type and dosage according to treating physician) or no BB treatment within 8 days of MI. The study is event driven and a power calculation for the combined DANBLOCK-BETAMI trial has been performed in which 950 events will provide a power of 80% to detect a true treatment effect equal to a hazard ratio of 1.2 for no beta-blocker therapy. Follow-up: Patients will be followed from the randomization date until end of follow-up. The last patient included will be followed for a minimum of 6 months. Estimated mean (non) treatment duration is 3 (0.5-6) years.

Post-trial objective:

• To perform a joint analysis of the data from BETAMI-DANBLOCK with the REDUCE (NCT03278509) and REBOOT (NCT03596385) trials. This analysis will comprise approximately 19000 patients, giving increased power and precision for clinical decisions on both primary and secondary endpoints.

Study Type

Interventional

Enrollment (Actual)

2895

Phase

  • Phase 4

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Contact Backup

Study Locations

      • Arendal, Norway
        • Sørlandet sykehus
      • Bergen, Norway
        • Haukeland Universitetssykehus
      • Bodø, Norway
        • Nordlandssykehuset HF Bodø
      • Drammen, Norway
        • Drammen Hospital
      • Fredrikstad, Norway
        • Sykehuset Østfold Kalnes
      • Gjøvik, Norway
        • Sykehuset Innlandet HF, Gjøvik Sykehus
      • Hamar, Norway
        • Sykehuset Innlandet Hamar
      • Hønefoss, Norway
        • Vestre Viken HF, Ringerike Sykehus
      • Lillehammer, Norway
        • Sykehuset Innlandet Lillehammer
      • Lørenskog, Norway
        • AHUS
      • Lørenskog, Norway
        • LHL Gardermoen
      • Oslo, Norway
        • Lovisenberg Diakonale Sykehus
      • Oslo, Norway
        • Diakonhjemmet Sykehus
      • Oslo, Norway
        • Oslo University Hospital Rikshospitalet, Dept.of Cardiology
      • Oslo, Norway
        • Oslo University Hospital Ullevaal, Dept. of Cardiology
      • Sandvika, Norway
        • Vestre Viken HF, Bærum Sykehus
      • Stavanger, Norway
        • Stavanger universitetssjukehus
      • Tromsø, Norway
        • Universitetssykehuset Nord-Norge, UNN
      • Trondheim, Norway
        • St. Olavs University Hospital
      • Tønsberg, Norway
        • Vestfold hospital

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Description

Inclusion Criteria

To be eligible for inclusion in the study, subjects must fulfill the following criteria at inclusion:

  • 18 years or older
  • Diagnosed with an acute MI type I according to the "Universal Definition of MI" (Defined as a detection of a rise and/or fall of cardiac biomarker value, preferably troponin, with at least one value above the 99th percentile upper reference limit and with at least one of the following; a) symptoms of ischemia, b) new or presumed new significant ST-segment-T wave changes or new left bundle branch block, c) development of pathological Q waves, d) imaging evidence of new loss of viable myocardium or e) identification of an intracoronary thrombus by coronary angiogram)
  • Must have been treated with PCI or thrombolysis during current hospitalization
  • Signed informed consent and expected cooperation of the patient according to ICH/GCP and national/local regulations
  • Have a national personal identification number and not be expected to emigrate during study

Exclusion Criteria

Study subjects must not meet any of the following criteria:

  • Having a condition where betablocker-therapy is required, including but not limited to:

    • Arrhythmias
    • Hypertension
    • Cardiomyopathies
    • Clinical diagnosis of heart failure
    • LVEF < 40% by echocardiography (by measurement and not only visual assessment for STEMI patients)
    • Left ventricular akinesia in ≥ 3 segments regardless of the LVEF
  • Contraindications to betablocker-therapy, including but not limited to:

    • Bradyarrhythmias
    • Hypotension
    • Severe peripheral artery disease
    • Previously known side-effects causing withdrawal
    • Severe chronic obstructive pulmonary disease
    • • Women of childbearing potential (a woman is considered of childbearing potential, i.e. fertile, following menarche and until becoming post-menopausal unless permanently sterile)
  • Known hypersensitivity to any ingredient of the IMP
  • Other, according to the responsible investigator
  • End-stage somatic disease with short life expectancy, dementia, psychosis and other conditions could put the subject at significant risk, confound the study results, interfere significantly with the subject participation in the study, or rendering informed consent unfeasible

Previous treatment with a betablocker is not an exclusion criterion for enrollment into the BETAMI study. Enrolled patients can participate in any other study that does not directly alter the effect betablocker treatment

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Active Comparator: Betablocker
Patients receiving a betablocker. Any other treatment or management is to be given as per usual care.

A betablocker will be administered. To reflect contemporary management, for which this study is designed to test, there will not be a defined minimum dosage. The type and dose of BB will be left at the discretion of the PI. Generic drug and accepted dosages will be:

  • Metoprolol succinate up to a total dose of 200mg daily
  • Bisoprolol up to a total dose of 10mg daily
  • Carvedilol up to a total dose of 50mg daily

The treating physician will be encouraged to aim for an equipotent dose of 100 mg metoprolol succinate or higher. Any other treatment or management is to be given as per usual care.

Experimental: Non-Betablocker
No betablocker is given to this arm. Any other treatment or management is to be given as per usual care.
No betablocker will be administered. Patients randomized to no beta-blockade will be discouraged to use beta-blockade as long as there is no other indication than strictly secondary prevention after myocardial infarction. Any other treatment or management is to be given as per usual care.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
A composite of death of any cause, recurrent myocardial infarction, incident heart failure, coronary revascularization, ischemic stroke, malignant ventricular arrhythmia or resuscitated cardiac arrest
Time Frame: 6 months (minimum) to 6 years (maximum)
Incidence of combined endpoint from randomization. Estimated maximal follow-up for each patient for this outcome is 6 months to 6 years
6 months (minimum) to 6 years (maximum)

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Recurrent MI
Time Frame: 6 months (minimum) to 6 years (maximum)
Time to recurrent MI from randomization. Estimated maximal follow-up for each patient for this outcome is 6 months to 6 years
6 months (minimum) to 6 years (maximum)
All-cause death
Time Frame: 6 months (minimum) to 6 years (maximum)
Time to a-cause Death from randomization. Estimated maximal follow-up for each patient for this outcome is 6 months to 6 years
6 months (minimum) to 6 years (maximum)
Malignant ventricular arrhythmia
Time Frame: 6 months (minimum) to 6 years (maximum)
Time to malignant ventricular arrhythmia from randomization. Estimated maximal follow-up for each patient for this outcome is 6 months to 6 years
6 months (minimum) to 6 years (maximum)
Hospitalization or outpatient consultation for incident heart failure
Time Frame: 6 months (minimum) to 6 years (maximum)
Time to hospitalization or outpatient consultation for heart failure from randomization. Estimated maximal follow-up for each patient for this outcome is 6 months to 6 years
6 months (minimum) to 6 years (maximum)
Unplanned coronary revascularization
Time Frame: 6 months (minimum) to 6 years (maximum)
Time to unplanned coronary revascularization from randomization. Estimated maximal follow-up for each patient for this outcome is 6 months to 6 years
6 months (minimum) to 6 years (maximum)
Ischemic stroke
Time Frame: 6 months (minimum) to 6 years (maximum)
Time to ischemic stroke from randomization. Estimated maximal follow-up for each patient for this outcome is 6 months to 6 years
6 months (minimum) to 6 years (maximum)
Resuscitated cardiac arrest
Time Frame: 6 months (minimum) to 6 years (maximum)
Time to resuscitated cardiac arrest from randomization. Estimated maximal follow-up for each patient for this outcome is 6 months to 6 years
6 months (minimum) to 6 years (maximum)
Cardiovascular death
Time Frame: 6 months (minimum) to 6 years (maximum)
Time to cardiovascular death from randomization. Estimated maximal follow-up for each patient for this outcome is 6 months to 6 years
6 months (minimum) to 6 years (maximum)
Hospitalization for stable and unstable angina
Time Frame: 6 months (minimum) to 6 years (maximum)
Time to hospitalization for stable and unstable angina from randomization. Estimated maximal follow-up for each patient for this outcome is 6 months to 6 years
6 months (minimum) to 6 years (maximum)
Hospitalization for atrial fibrillation, atrial flutter or other atrial tachyarrhythmias
Time Frame: 6 months (minimum) to 6 years (maximum)
Time to hospitalization for atrial fibrillation, atrial flutter or other atrial tachyarrhythmias from randomization. Estimated maximal follow-up for each patient for this outcome is 6 months to 6 years
6 months (minimum) to 6 years (maximum)
Hospitalization for bradycardia, syncope or implantation of pacemaker
Time Frame: 6 months (minimum) to 6 years (maximum)
Time to hospitalization for bradycardia, syncope or implantation of pacemaker from randomization. Estimated maximal follow-up for each patient for this outcome I 6 months to 6 years
6 months (minimum) to 6 years (maximum)
Hospitalization for chronic obstructive pulmonary disease, asthma or peripheral artery disease
Time Frame: 6 months (minimum) to 6 years (maximum)
Time to hospitalization for chronic obstructive pulmonary disease, asthma or peripheral artery disease from randomization. Estimated maximal follow-up for each patient for this outcome is 6 months to 6 years
6 months (minimum) to 6 years (maximum)
Hospitalization or outpatient visit for new-onset or dysregulated diabetes
Time Frame: 6 months (minimum) to 6 years (maximum)
Time to hospitalization hospitalization or outpatient visit for new-onset or dysregulated diabetes from randomization. Estimated maximal follow-up for each patient for this outcome is 6 months to 6 years
6 months (minimum) to 6 years (maximum)
Angina symptoms
Time Frame: Through self-report questionnaires administered at inclusion, 30 days, 3,6 and 18 months
Canadian Cardiovascular Society (CCS) grading of angina pectoris.
Through self-report questionnaires administered at inclusion, 30 days, 3,6 and 18 months
Health-related quality of life
Time Frame: Through self-report questionnaires administered at inclusion, 30 days, 3,6 and 18 months
Health-related quality of life measured by the Short Form (SF) 12
Through self-report questionnaires administered at inclusion, 30 days, 3,6 and 18 months
Measures of depression and anxiety
Time Frame: Through self-report questionnaires administered at inclusion, 30 days, 3,6 and 18 months
HADS (Hospital Anxiety and Depression Scale)
Through self-report questionnaires administered at inclusion, 30 days, 3,6 and 18 months
Measures of sexual dysfunction
Time Frame: Through self-report questionnaires administered at inclusion, 30 days, 3,6 and 18 months
The International Index of Erectile Function (IIEF) and Female Sexual Function Index (FSFI)
Through self-report questionnaires administered at inclusion, 30 days, 3,6 and 18 months
Measures of sleep disorders
Time Frame: Through self-report questionnaires administered at inclusion, 30 days, 3,6 and 18 months
Bergen insomnia Scale
Through self-report questionnaires administered at inclusion, 30 days, 3,6 and 18 months
Measures of sleep disorders
Time Frame: Through self-report questionnaires administered at inclusion, 30 days, 3,6 and 18 months
Bergen insomnia Scale and sleep duration
Through self-report questionnaires administered at inclusion, 30 days, 3,6 and 18 months
Measures of Nightmare Frequency
Time Frame: Through self-report questionnaires administered at inclusion, 30 days, 3,6 and 18 months
Nightmare Frequency Questionnaire
Through self-report questionnaires administered at inclusion, 30 days, 3,6 and 18 months

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

October 1, 2018

Primary Completion (Estimated)

December 10, 2024

Study Completion (Estimated)

December 10, 2034

Study Registration Dates

First Submitted

May 14, 2018

First Submitted That Met QC Criteria

August 23, 2018

First Posted (Actual)

August 24, 2018

Study Record Updates

Last Update Posted (Estimated)

March 1, 2024

Last Update Submitted That Met QC Criteria

February 29, 2024

Last Verified

February 1, 2024

More Information

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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