Is the efficacy of bisoprolol in secondary prevention of acute myocardial infarction in patients after percutaneous coronary intervention comparable to carvedilol?
Beta-blockers (BB) are recommended for all patients after percutaneous coronary intervention (PCI) as part of secondary prevention of acute myocardial infarction (AMI). The study presented below compared the efficacy of carvedilol – a vasodilating beta-blocker, whose benefit in this indication was confirmed by a randomized clinical trial – with the effect of bisoprolol.
Methodology and Study Course, Population Observed
A total of 13,813 patients from the Korean Acute Myocardial Infarction Registry (KAMIR) were included in the multicenter retrospective observational study cohort. All were over 18 years old and had undergone PCI for acute myocardial infarction, after which they used bisoprolol or carvedilol as part of secondary prevention of AMI. After selecting balanced samples using the propensity score matching method in a 1:2 ratio, the final analysis included 1,806 patients who were treated with bisoprolol (selective β1-blocker) and 3,612 who were using carvedilol (nonselective BB of the 3rd generation with vasodilating effect) post-discharge. Initial dosing was individualized, followed by titration according to the clinical status of the patient. In case of adverse effects (bradycardia, hypotension), use was discontinued.
Exclusion criteria were as follows:
- absence of significant coronary artery stenosis on angiography
- MI as a result of coronary artery spasm
The primary endpoint was the incidence of major adverse cardiac events (MACE) during 2 years of bisoprolol or carvedilol usage. MACE were defined as cardiac death, recurrent non-fatal MI (recurrent clinical symptoms or new changes on ECG with elevation of cardiac markers to at least 2 times the upper reference limit), repeat PCI (revascularization) on the same artery, or coronary bypass surgery. The secondary endpoint included overall mortality and revascularization on a different artery.
Results
Patients were followed for an average of 10.2 months. After adjusting for baseline parameters (systolic and diastolic blood pressure, type of MI, left ventricular ejection fraction, heart failure grade according to the Killip classification, levels of cardiac markers and CRP in blood, use of RAAS inhibitors, statins, and spironolactone), no significant difference was observed in the incidence of MACE between patients using bisoprolol and carvedilol (hazard ratio [HR] 0.815; 95% confidence interval [CI] 0.614–1.081; p = 0.156). Similar results were found for overall survival (HR 0.937; 95% CI 0.646–1.357; p = 0.729). The incidence of secondary outcomes was also comparable between the two groups.
The incidence of MACE was lower in patients with heart failure grade III (cardiac pulmonary edema) and IV (cardiogenic shock) according to the Killip classification in the bisoprolol group (HR 0.512; 95% CI 0.263–0.998; p = 0.049). For patients classified as grade I (no clinical signs of heart failure) and II (lung crackles), no significant difference in the incidence of MACE was observed between the bisoprolol and carvedilol groups. Other characteristics considered in the subgroup analysis (age, type of MI, left ventricular ejection fraction, presence or absence of hypertension, diabetes mellitus, and hyperlipidemia) did not significantly influence the relationship between bisoprolol and carvedilol efficacy in reducing MACE.
Discussion and Conclusion
The study demonstrated that the benefit of bisoprolol in secondary prevention of acute myocardial infarction in patients after percutaneous coronary intervention is at least comparable to the benefit of carvedilol. The overall comparable efficacy of bisoprolol with carvedilol was consistent across subgroups, except for patients with more severe grades of heart failure, where bisoprolol was even more effective. Thus, bisoprolol is at least as cardioprotective in this indication as the vasodilating third-generation beta-blocker carvedilol.
The study was limited by the short follow-up period and the lack of data on beta-blocker dosing and titration for individual patients. Therefore, their long-term efficacy or the efficacy of specific doses cannot be evaluated. In the future, a randomized controlled trial should verify the efficacy of bisoprolol in this indication.
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Source: Jun S. J., Kim K. H., Jeong M. H. et al. Effects of bisoprolol are comparable with carvedilol in secondary prevention of acute myocardial infarction in patients undergoing percutaneous coronary intervention. Chonnam Med J 2018; 54 (2): 121–128, doi: 10.4068/cmj.2018.54.2.121.
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