BMJ 1999;318:1730-1737 ( 26 June )

Papers

beta Blockade after myocardial infarction: systematic review and meta regression analysis

Nick Freemantle, senior research fellow, a John Cleland, professor, b Philip Young, lecturer in applied statistics, c James Mason, senior research fellow, a Jane Harrison, information officer. a

a Medicines Evaluation Group, Centre for Health Economics, University of York, York YO10 5DD, b Department of Cardiology, Castle Hill Hospital, University of Hull, Kingston upon Hull, U16 5JQ, c Department of Health Sciences and Clinical Evaluation, University of York

Correspondence to: N Freemantle meg{at}york.ac.uk

Objectives: To assess the effectiveness of beta  blockers in short term treatment for acute myocardial infarction and in longer term secondary prevention; to examine predictive factors that may influence outcome and therefore choice of drug; and to examine the clinical importance of the results in the light of current treatment.
Design: Systematic review of randomised controlled trials.
Setting: Randomised controlled trials.
Subjects: Patients with acute or past myocardial infarction.
Intervention: beta Blockers compared with control.
Main: outcome measures All cause mortality and non-fatal reinfarction.
Results: Overall, 5477 of 54 234 patients (10.1%) randomised to beta  blockers or control died. We identified a 23% reduction in the odds of death in long term trials (95% confidence interval 15% to 31%), but only a 4% reduction in the odds of death in short term trials (-8% to 15%). Meta regression in long term trials did not identify a significant reduction in effectiveness in drugs with cardioselectivity but did identify a near significant trend towards decreased benefit in drugs with intrinsic sympathomimetic activity. Most evidence is available for propranolol, timolol, and metoprolol. In long term trials, the number needed to treat for 2 years to avoid a death is 42, which compares favourably with other treatments for patients with acute or past myocardial infarction.
Conclusions: beta Blockers are effective in long term secondary prevention after myocardial infarction, but they are underused in such cases and lead to avoidable mortality and morbidity.


Key messages

  • The first randomised trials of beta  blockade in secondary prevention after myocardial infarction were published in the 1960s

  • beta blockers were once heralded as a major advance, but their use for secondary prevention has declined in recent years

  • Firm evidence shows that long term beta  blockade remains an effective and well tolerated treatment that reduces mortality and morbidity in unselected patients after myocardial infarction

  • The benefits from beta  blockade compare favourably with other drug treatments for this patient group

  • Most evidence is for propranolol, timolol, and metoprolol, whereas atenolol, which is commonly used, is inadequately evaluated for long term use




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Rapid Responses:

Read all Rapid Responses

Atenolol after myocardial infarction - absence of evidence is a failure of research policy
Toby Lipman
bmj.com, 26 Jun 1999 [Full text]
Long term b blocker use following acute myocardial infarction
Kent L Woods
bmj.com, 19 Aug 1999 [Full text]
Delayed beta-blockade
Nigel Thorpe
bmj.com, 23 Mar 2001 [Full text]
Significant adverse effects, particularly in the elderly, as also associated with beta Blockade
Robert Eli
bmj.com, 5 Dec 2007 [Full text]
The authors fail to consider possible adverse effects of Beta Blockade, particularly in the elderly patient
Robert Eli
bmj.com, 13 Feb 2009 [Full text]
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