Early beta-blocker use post-PCI tied to reduced in-hospital bleeding risk
Initiation of oral beta-blockers within 24 hours following PCI for ACS was associated with reduced risk for in-hospital bleeding and mortality compared with nonuse, researchers reported.
According to data published in the European Heart Journal: Quality Care and Clinical Outcomes, the observed reductions in risk for major in-hospital bleeding were dose-dependent and did not differ by use of either metoprolol or bisoprolol.
“During the past two decades, there is a doubling of bleeding events in ACS patients following PCI, which is the most common and costly noncardiac complication associated with poor prognosis. The role of beta-blocker in ACS patient management was established in the early 1960s,” Shaopeng Xu, MD, PhD, of the department of cardiology at Tianjin Medical University General Hospital in Tianjin, China, and colleagues wrote. “Despite the recent reports from observational studies questioning the benefit of long-term use of beta-blocker following ACS, current guidelines recommend the routine use of early oral beta-blockers during ACS hospitalization. Notably, scattered reports from the late 1990s and early 2000s provided clues indicating a potential role of beta-blocker therapy in reducing bleeding complications.”
Researchers utilized data from the Improving Care for Cardiovascular Disease in China-ACS project to ascertain whether oral beta-blocker initiation with 24 hours after PCI reduced risk for in-hospital bleeding compared with nonuse; whether the association was dose-dependent; and whether there was a difference in bleeding risk between common oral beta-blockers, such as metoprolol and bisoprolol.
The CCC-ACS project is a collaboration between the American Heart Association and the Chinese Society of Cardiology to improve of the management of ACS in 150 hospitals across China.
Among 43,640 patients without beta-blocker contraindications, 36% received oral beta-blocker within 24 hours after PCI (89.6% received metoprolol; 10.4% received bisoprolol). A total of 637 major in-hospital bleeds and 476 occurred.
Early oral beta-blocker initiation was associated with reduced risk for major in-hospital bleeding (OR = 0.48; 95% CI, 0.38-0.61) and in-hospital mortality (OR = 0.47; 95% CI, 0.34-0.64) compared with non-use of beta-blockers.
The benefits of reduced bleeding risk with early beta-blocker use were strengthened in a dose dependent manner when compared with non-use:
- metoprolol-equivalent dose less than 50 mg per day (OR = 0.61; 95% CI, 0.47-0.79); and
- metoprolol-equivalent dose 50 mg per day or more (OR = 0.47; 95%CI, 0.33-0.68).
Researchers reported that early bisoprolol use was not associated with risk for major in-hospital bleeding compared with metoprolol, and there was no significant difference between high-dose bisoprolol and high-dose metoprolol for neither major in-hospital bleeding or death.
“The underuse and underdosing of oral [beta]-blockers for ACS patients is common in clinical practice ... According to current research, the problem of underuse and underdose of oral [beta]-blocker may be attributed to misleading selection of oral [beta]-blocker based on standard tablet formulations,” the researchers wrote. “Based on our finding, in most cases without contraindications, it is reasonable to start metoprolol at 50 mg/day, considering the equivalent starting dose of bisoprolol was usually 2.5 mg/day in real-world practice. Notably, this dose is only the 25% of metoprolol target dose (200mg/day). To maximize the clinical benefit of early oral [beta]-blocker, specific efforts targeting the above-mentioned two issues concerning the underuse and underdosing in ACS patients are needed in the future.”
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