The headliner: Beta-blockers offer no benefit after MI when LVEF is preserved
For decades, beta-blockers after myocardial infarction have been treated as default therapy, but this practice has been supported by trials that date back to the 1980s. Enter this large individual-patient meta-analysis, pooling 17,801 patients across five recent randomized trials of patients with recent MI and LVEF ≥50% and no other indication for beta-blockers. The primary composite outcome (death, MI, or heart failure) occurred in 8.1% of patients on beta-blockers and 8.3% of those not treated (HR 0.97; 95% CI 0.87–1.07), showing no meaningful difference. None of the individual components—death, recurrent MI, or heart failure—were improved with therapy. In short, for post-MI patients with preserved LVEF, routine beta-blockers don’t improve outcomes and may represent yet another legacy practice ready for retirement.
The hidden gem: Spironolactone for patients on dialysis doesn’t improve CV endpoints
Patients with end-stage renal disease requiring dialysis are at high risk of subsequent cardiovascular events. The ACHIEVE trial sought to determine if spironolactone can reduce this risk. It was an international, placebo-controlled, double-blind trial, and the primary endpoint was a composite of CV mortality or hospitalization for heart failure. Following a planned interim analysis, the external safety and efficacy monitoring committee recommended stopping the trial early due to futility. Overall, 2538 were randomly assigned to spironolactone (n=1260) or placebo (n=1278). The composite primary outcome occurred in 258 participants in the spironolactone group and in 276 participants in the placebo group (hazard ratio [HR] 0·92 [95% CI 0·78–1·09]; p=0·35).
The take home points:
[1] In patients with preserved LVEF (≥50%) and no other indication, beta-blockers offered no reduction in death, MI, or HF.
[2] Spironolactone did not reduce CV death or HF hospitalization in patients on dialysis, leading to early termination for futility.