Benefit of Immediate Beta-Blocker Therapy on Mortality in Patients With ST-Segment Elevation Myocardial Infarction

Hirschl, Michael M. MD; Wollmann, Christian G. MD; Erhart, Friedrich MD; Brunner, Walter MD; Pfeffel, Franz MD; Gattermeier, Martin MD; Steger, Friedrich MD; Mayr, Harald MD

Published Ahead-of-Print

Abstract

Objectives: Despite the recommendations to initiate [beta]-blockade to all patients with an ST-segment elevation myocardial infarction, data concerning the timing of the administration of [beta]-blockers are controversially discussed. In view of these controversies, we analyzed the effect of immediate vs. delayed [beta]-blockade on all-cause mortality of patients with ST-segment elevation myocardial infarction in the Lower Austrian Myocardial Infarction Network.

Design: Nonrandomized, prospective observational cohort study.

Setting: Myocardial infarction network including the out-of-hospital emergency services, five primary-care hospitals and a percutaneous coronary intervention-capable hospital in the western part of Lower Austria.

Patients: The data of all patients with ST-segment elevation myocardial infarction defined according to the American Heart Association criteria and treated according to the treatment protocol of the network were consecutively collected. For the purpose of survival analyses, the baseline survival time was set to 48 hours after the first electrocardiogram, and in all patients with recurrent MI within the observational period, only the first MI was regarded.

Interventions: The treatment protocol recommended either the immediate oral administration of 2.5 mg bisoprolol (within 30 min after the first electrocardiogram) or 24 hours after acute myocardial infarction (delayed [beta]-blockade).

Measurements and Main Results: In total, out of the 664 patients with ST-segment elevation myocardial infarction, 343 (n = 52%) received immediate [beta]-blockade and 321 (48%) received delayed [beta]-blockade. The probability of any death (baseline survival time: 48 hrs after first electrocardiogram; 640 patients) was 19.2% in the delayed treatment group and 10.7% in the immediate treatment group (p = 0.0022). Also the probability of cardiovascular mortality was significantly lower in the immediate [beta]-blocker treatment group (immediate treatment group: 9 (5.2%); delayed treatment group: 30 (13.4%); p = 0.0002). Multivariable Cox regression analysis identified immediate [beta]-blocker therapy to be independently protective against death of any cause (odds ratio: 0.55, p = 0.033).

Conclusion: Immediate [beta]-blocker administration in the emergency setting is associated with a reduction of all-cause and cardiovascular mortality in patients with ST-segment elevation myocardial infarction and seems to be superior to a delayed [beta]-blockade in our patient cohort.

(C) 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins

Heart Attack Update: Day 60

It’s been two months to the day since my heart attack — here’s an update:

So far, I am asymptomatic except I still tire easily.  Since I am still taking a heavy dose of medications designed to keep my heart from working too hard, it’s difficult to walk inclines — flat or downhill no problem.  Plus I am somewhat short-tempered.  People who know me have noticed.

I participate in monitored cardiac rehab 3x a week which means I am sore most of the time.  This may have to do with the heavy dose of statins that I am on, as well.

I am down 20lbs to 165lbs and trying to keep it there or even just a bit lower.  Cheese and organ meats are out entirely; I still enjoy wine but candidly the flavors are different now so have been cutting back.  Also cutting back on carbs as much as I can — difficult.  Lots of salad lately.  I am especially fond of the “big bowl” salad with tuna at The Creperie (corner of Polk and Washington).  Very light dressing and the tuna is made without mayonnaise (as far as I can tell).

Naturally I’ve been sharing ideas with other cardiac patients.  I have found that many have not suffered heart attacks as I did but we’re alerted by symptoms or by their physician during an annual exam.  Sadly, not my fate.  My heart is damaged and I am doing all I can to rehabilitate it.

I am up between 530a and 6a daily — this allows me to call over to east coast clients for Informedika.  I tend to tire out around 4p — this is vastly improved from a month ago when I was napping all afternoon.

My next ECHO is mid-July; I am hoping for 50% or higher.  Perhaps my drug regimen can be modified at that time, as well.

Steve

Before & After

ST segment elevation myocardial infarction

Last Wednesday morning I had a massive heart attack.  As you can see above, the LAD was 100% blocked and is not even visible on the initial cath scan.  In the past, this type of cardiac event has been called “the widow maker” and prompted open heart surgery.  In my case, I was able to have a stent placed.

Thanks to my wife and CPMC, I am recuperating at home now.