β blockers and mortality after myocardial infarction in patients without heart failure: multicentre prospective cohort study

Abstract

Objective: To assess the association between early and prolonged β blocker treatment and mortality after acute myocardial infarction.

Design: Multicentre prospective cohort study.

Setting: Nationwide French registry of Acute ST- and non-ST-elevation Myocardial Infarction (FAST-MI) (at 223 centres) at the end of 2005.

Participants: 2679 consecutive patients with acute myocardial infarction and without heart failure or left ventricular dysfunction.

Main outcome measures: Mortality was assessed at 30 days in relation to early use of β blockers (≤48 hours of admission), at one year in relation to discharge prescription, and at five years in relation to one year use.

Results: β blockers were used early in 77% (2050/2679) of patients, were prescribed at discharge in 80% (1783/2217), and were still being used in 89% (1230/1383) of those alive at one year. Thirty day mortality was lower in patients taking early β blockers (adjusted hazard ratio 0.46, 95% confidence interval 0.26 to 0.82), whereas the hazard ratio for one year mortality associated with β blockers at discharge was 0.77 (0.46 to 1.30). Persistence of β blockers at one year was not associated with lower five year mortality (hazard ratio 1.19, 0.65 to 2.18). In contrast, five year mortality was lower in patients continuing statins at one year (hazard ratio 0.42, 0.25 to 0.72) compared with those discontinuing statins. Propensity score and sensitivity analyses showed consistent results.

Conclusions: Early β blocker use was associated with reduced 30 day mortality in patients with acute myocardial infarction, and discontinuation of β blockers at one year was not associated with higher five year mortality. These findings question the utility of prolonged β blocker treatment after acute myocardial infarction in patients without heart failure or left ventricular dysfunction.Trial registration Clinical trials NCT00673036.

Conflict of interest statement

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: EP has received speaker, board membership, and consulting fees from Amgen, AstraZeneca, Bayer, Daiichi Sankyo, Lilly, MSD, and Sanofi-Aventis; SC has received grants from AstraZeneca, Boehringer Ingelheim, Boston Scientific, Medtronic, and Servier; GS has received institutional research grant support from NYU School of Medicine, Sanofi-Aventis, and Servier and consulting/advisory board fees from Ablynx, Amarin, Astellas, AstraZeneca, Bayer, Boehringer-Ingelheim, BMS, Daiichi-Sankyo-Lilly, GSK, Medtronic, MSD, Novartis, Otsuka, Pfizer, Roche, Sanofi-Aventis, Servier, and The Medicines Company and is a stockholder and co-founder of Aterovax; FS has received grant support to his institution and travel support for scientific meetings from AstraZeneca, Boehringer-Ingelheim, Daiichi-Sankyo, Lilly, Medtronic, Pfizer; Sanofi-Aventis, Servier, and Takeda; JF has received grants and speaker fees from AstraZeneca, Genzyme, Merck, Novartis, and Servier. TS has received research grants from Astra-Zeneca, Daiichi-Sankyo, Eli-Lilly, Glaxo-Smith-Kline, MSD, Novartis, Pfizer, Sanofi-Aventis, and Servier and speaker and consulting fees from AstraZeneca, Bayer-Schering, Eli-Lilly, and Sanofi-Aventis; ND has received research grants from AstraZeneca, Daiichi-Sankyo, Eli-Lilly, Glaxo-Smith-Kline, MSD, Novartis, Pfizer, Sanofi-Aventis, Servier, and The Medicines Company and advisory panel or lecture fees from AstraZeneca, Boehringer-Ingelheim, Bristol-Myers Squibb, Eli-Lilly, Menarini, Merck-Serono, Novo-Nordisk, Servier, and Sanofi-Aventis; no other relationships or activities that could appear to have influenced the submitted work.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Figures

Fig 1 Flowchart of populations from FAST-MI studied at different time points. LVEF=left ventricular ejection fraction

Fig 2 Survival according to β blocker use. A: 30 day survival according to β blocker use during first 48 hours after admission in patients with no history of heart failure and no heart failure on admission (population 1). B: one year survival according to β blocker prescription at discharge in patients with no history of heart failure and no documented left ventricular dysfunction (population 2). C: five year survival in patients discharged taking β blockers, according to continuation of β blocker treatment at one year (population 3). HR=hazard ratio