Archive for the ‘Drug therapy’ Category

Journal Club 20 February 2013


Beta-Blocker Use and Clinical Outcomes in Stable Outpatients With and Without Coronary Artery Disease





Beta-Blockers remain the standard of care after a myocardial infarction (MI).
However, the benefit of beta-blocker use in patients with coronary artery disease (CAD)
but no history of MI, those with a remote history of MI, and those with only risk factors
for CAD is unclear.


To assess the association of beta-blocker use with cardiovascular events in
stable patients with a prior history of MI, in those with CAD but no history of MI, and
in those with only risk factors for CAD.

Design, Setting, and Patients

Longitudinal, observational study of patients in the
Reduction of Atherothrombosis for Continued Health (REACH) registry who were divided
into 3 cohorts: known prior MI (n=14 043), known CAD without MI (n=12 012),
or those with CAD risk factors only (n=18 653). Propensity score matching was used
for the primary analyses. The last follow-up data collection was April 2009.

Main Outcome Measures

The primary outcome was a composite of cardiovascular
death, nonfatal MI, or nonfatal stroke. The secondary outcome was the primary
outcome plus hospitalization for atherothrombotic events or a revascularization procedure.


Among the 44 708 patients, 21 860 were included in the propensity score–
matched analysis. With a median follow-up of 44 months (interquartile range, 35-45
months), event rates were not significantly different in patients with beta-blocker use compared
with those without beta-blocker use for any of the outcomes tested, even in the prior
MI cohort (489 [16.93%] vs 532 [18.60%], respectively; hazard ratio [HR], 0.90 [95%
CI, 0.79-1.03]; P=.14). In the CAD without MI cohort, the associated event rates were
not significantly different in those with beta-blocker use for the primary outcome (391
[12.94%]) vs without beta-blocker use (405 [13.55%]) (HR, 0.92[95%CI, 0.79-1.08]; P=.31),
with higher rates for the secondary outcome (1101 [30.59%] vs 1002 [27.84%]; odds
ratio [OR], 1.14 [95% CI, 1.03-1.27]; P=.01) and for the tertiary outcome of hospitalization
(870 [24.17%] vs 773 [21.48%]; OR, 1.17 [95% CI, 1.04-1.30]; P=.01). In the
cohort with CAD risk factors only, the event rates were higher for the primary outcome
with beta-blocker use (467 [14.22%]) vs without beta-blocker use (403 [12.11%]) (HR, 1.18
[95% CI, 1.02-1.36]; P=.02), for the secondary outcome (870 [22.01%] vs 797 [20.17%];
OR, 1.12 [95% CI, 1.00-1.24]; P=.04) but not for the tertiary outcomes of MI (89 [2.82%]
vs 68 [2.00%]; HR, 1.36 [95% CI, 0.97-1.90]; P=.08) and stroke (210 [6.55%] vs 168
[5.12%]; HR, 1.22 [95% CI, 0.99-1.52]; P=.06). However, in those with recent MI (1
year), beta-blocker use was associated with a lower incidence of the secondary outcome
(OR, 0.77 [95% CI, 0.64-0.92]).


In this observational study of patients with either CAD risk factors only,
known prior MI, or known CAD without MI, the use of beta-blockers was not associated
with a lower risk of composite cardiovascular events

Dabigatran: periprocedural and bleeding management

A useful paper regarding managing patients  on dabigatran undergoing invasive procedures or having bleeding is here.

Journal Club 3 October 2012


Bleeding After Initiation of Multiple Antithrombotic Drugs, Including Triple Therapy, in Atrial Fibrillation Patients Following Myocardial Infarction and Coronary Intervention





Uncertainty remains over optimal antithrombotic treatment of patients with atrial fibrillation presenting with
myocardial infarction and/or undergoing percutaneous coronary intervention. We investigated the risk and time frame
for bleeding following myocardial infarction/percutaneous coronary intervention in patients with atrial fibrillation
according to antithrombotic treatment.

Methods and Results

Patients with atrial fibrillation and admitted with myocardial infarction or for percutaneous coronary
intervention between 2000 and 2009 (11 480 subjects, mean age 75.6 years [SD 10.3], males 60.9%) were identified by
individual level linkage of nationwide registries in Denmark. Fatal or nonfatal (requiring hospitalization) bleeding was
determined according to antithrombotic treatment regimen: triple therapy (TT) with vitamin K antagonist
(VKA)aspirinclopidogrel, VKAantiplatelet, and dual antiplatelet therapy with aspirinclopidogrel. We calculated crude
incidence rates and adjusted hazard ratios by Cox regression models. Within 1 year, 728 bleeding events were recorded (6.3%); 79 were fatal (0.7%). Within 30 days, rates were 22.6, 20.3, and 14.3 bleeding events per 100 person-years for TT, VKAantiplatelet,
and dual antiplatelet therapy, respectively. Both early (within 90 days) and delayed (90–360 days) bleeding risk with TT exposure
in relation to VKAantiplatelet was increased; hazard ratio 1.47 (1.04;2.08) and 1.36 (0.95;1.95), respectively. No significant
difference in thromboembolic risk was observed for TT versus VKAantiplatelet; hazard ratio, 1.15 (0.95;1.40).


High risk of bleeding is immediately evident with TT after myocardial infarction/percutaneous coronary
intervention in patients with atrial fibrillation. A continually elevated risk associated with TT indicates no safe therapeutic window, and TT should only be prescribed after thorough bleeding risk assessment of patients.

Other Material

The editorial is here.

ESC Taskforce on New Anticaogulants for Atrial Fibrillation and Acute Coronary Syndromes

A very useful review paper from the European Society of Cardiology Working Group on Thrombosis is available here.